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FisKE  Fund  Prize  Dissertation,      No,  L, 


Diet  in  Typhoid  Fever 


MIOTTO: 

"Jobeni." 


JOHN    BENJAMIN   NICHOLS,    M.    D., 

1321  Rhode  Island  Avenue, 

Washington,  D.  C. 


PROVIDENCE: 

Snow  &  Farnham  Company,  Printers. 
1907. 


THE  Trustees  of  the  Fiske  Fund,  at  the  annual  meeting  of  the 
Rhode  Island  Medical  Society,  held  at  Providence,  June  6,  1907, 
announced  that  they  had  awarded  a  premium  of  two  hundred  and 
fifty  dollars   to   an   essay   on    "Diet  in  Typhoid  Fever,"  bearing   the 

motto : 

"  Jobeni." 

The  author  was  found  to  be  John  Benjamin  Nichols,  M.  D.,    of 
Washington,  D.  C. 

CHARLES   V.    CHAPIN,    M.  D.,    Providence,  R.  I., 
FRANK   B.  FULLER,    M.  D.,    Pawtucket,  R.  I., 
EUGENE   KINGMAN,    Providence,  R.  I., 

Trustees. 

HALSEY   DeWOLF,    M.  D.,    Providence, 

Secretary  of  the  Trustees. 


DIET  IN   TYPHOID   FEVER 


JOHN   B.   NICHOLS. 


In  the  preparafeion  of  this  paper,  liberal  use  has,  by  the  courtesy  of 
the  publishers,  been  made  of  previous  articles  by  the  writer  published 
in  American  Medicine,  May  6,  1905,  IX,  726-736,  and  the  Medical 
Record,  July  29,  1905,  LXVIII,  171-174. 


Diet  in  Typhoid  Fever. 


While  to  the  great  majority  of  physicians  it  may 
seem  that  the  question  of  feeding  in  typhoid  fever  has 
been  definitely  and  finally  settled,  there  are  a  few 
who  believe  that  finality  and  the  best  methods  have 
not  yet  been  attained.  It  is  the  purpose  of  this  paper 
to  consider  the  subject  in  all  its  phases. 

HISTORY    OF    DIETETICS    IN    TIPHOID    FEVER. 

The  evolution  of  dietetic  methods  in  typhoid  fever, 
even  of  concepts  dominant  at  the  present  day,  can  be 
traced  back  for  ages  before  typhoid  was  differentiated 
as  a  separate  disease,  even  to  the  dawn  of  medical  his- 
tory, the  era  of  Hippocrates.  Prior  to  the  time  when 
typhoid  was  definitely  distinguished  from  typhus  and 
other  fevers  the  ideas  of  the  medical  profession  as  to 
the  causes,  nature,  and  classification  of  the  febrile  dis- 
eases were  very  hazy  and  confused,  and  numerous  dis- 
tinct affections  were  considered  and  jumbled  together 
under  the  general  and  common  head  of  "  fever "  or 
*'  continued  fever." 

In  the  time  of  Hippocates  the  conceptions  of  fevers 
were  extremely  crude  and  indefinite.  As  to  bleeding 
and  the  emptying  of  the  alimentary  tract   by  emesis 


6  DIET  IN   TYPHOID   FEVER. 

and  purgation  in  fever,  the  teachings  of  Hippocrates 
were  not  very  definite,  systematic,  or  emphatic.  On 
the  question  of  diet  even  in  those  early  days  there 
were  conflicting  views,  some  insisting  on  absolute  star- 
vation for  a  greater  or  less  period,  others  advocating 
what  was  regarded  as  liberal  feeding,  one  Petronos 
being  mentioned  by  Galen  as  even  allowing  his  patients 
flesh  and  wine.  Hippocrates  seems  to  have  held  a 
middle  ground  between  the  starvation  and  feeding 
systems. 

The  article  of  food  mainly  and  almost  exclusively 
recommended  by  Hippocrates  in  fever  was  ''  ptisan  " 
or  barley  decoction,  which  he  allowed  rather  liberally ; 
he  discourses  at  great  length  on  its  preparation  and 
use,  whether  strained  or  unstrained,  thick  or  thin,  and 
the  proper  time  for  commencing  it.  The  use  of  ptisan 
was,  according  to  Galen,  based  on  the  principle  that 
as  fever  is  essentially  a  combination  of  heat  and  dry- 
ness, the  use  of  a  cooling  and  moistening  material  (like 
ptisan)  is  accordingly  indicated.  Hippocrates  also  al- 
lowed, under  proper  conditions,  the  use  of  wine,  hy- 
dromel  (honey  boiled  in  water),  and  oxymel  (honey 
acidulated  with  vinegar  or  acetic  acid) ;  he  was  not 
favorably  disposed  to  the  free  use  of  plain,  unflavored 
water  in  fever.  While  little  is  expressly  said,  the  use 
of  solid  food  and  of  beef  tea  and  soups,  etc.,  made  of 
animal  matter  was  apparently  entirely  rejected  by  the 
ancients,  and  Hippocrates  explicitly  states  that  milk  is 
a  bad  thing  to  give  in  fevers. 


DIET   IN   TYPHOID   FEVER.  7 

In  the  course  of  the  centuries  following-  Hippocrates 
the  phlogistic  theory  and  antiphlogistic  therapy  of 
fevers  became  definitely  crystallized  until  it  univer- 
sally and  completely  dominated  the  mind  and  practice 
of  the  medical  profession.  It  was  at  its  height  in  the 
seventeenth  century  (the  time  of  Sydenham),  and  was 
not  finally  overthrown  until  toward  the  middle  of  the 
last  century.  According  to  this  doctrine  fevers  were 
due  essentially  and  primarily  to  local  or  general  in- 
flammation, or  excessive  action  of  the  heart  and  arterial 
system  ;  they  were  of  sthenic  type  and  characterized 
by  over  excitement.  The  antiphlogistic  treatment, 
based  on  this  conception  of  the  pathology  of  fever  and 
for  Centuries  practically  universally  employed,  consisted 
in  the  use  of  vigorous  lowering  and  depleting  measures 
to  subdue  the  excitement,  especially  copious  and  re- 
peated bleeding  and  the  withholding  of  food.  Vigor- 
ous emesis  and  purgation  were  employed,  especially 
at  the  beginning  of  the  disease,  to  remove  noxious  and 
exciting  material  from  the  stomach  and  bowels.  The 
food  allowed,  in  general,  was  limited  to  gruels  (barley 
water  and  the  like),  along  with  a  liberal  amount  of 
flavored  drink  (acidulated,  sweetened,  mucilaginous, 
aromatic,  etc.),  and  occasionally  acid  fruits.  These 
were  selected  as  being  unstimulating  and  unirritating ; 
the  ingestion  of  large  amounts  of  water  was  supposed 
to  dilute  the  acrid  humors  of  the  body  ;  and  the  acid- 
ulous and  other  materials  used  being  refreshing  and 
grateful  to  the  taste  seemed  to  be  cooling  and  refrig- 
erant to  the  fever  process. 


8  DIET   IN   TYPHOID   FEVER. 

Animal  food  of  all  kinds  was  rigidly  excluded  from 
the  dietary,  as  it  was  believed  to  increase  the  body 
heat,  to  be  a  source  of  excitement  and  stimulation,  to 
be  incapable  of  digestion,  to  undergo  excessive  putre- 
faction, and  to  introduce  into  the  alimentary  canal 
noxious  and  acrid  matters.  The  prohibition  of  animal 
food  embraced  not  only  meat,  but  also  eggs,  milk, 
broths,  beef  tea,  meat  extracts,  etc. ;  and  so  deeply 
was  the  professional  mind  imbued  with  the  essential 
harmfulness  of  animal  food  that  a  marked  prejudice 
against  even  broths  and  bouillon  persisted  down  to  a 
recent  date.  Many  dietetic  theories  were  propounded 
by  different  authorities  which  in  the  light  of  modern 
knowledge  of  the  physiology  of  digestion  and  metabo- 
lism seem  grotesque.  The  digestive  powers  during 
fever  were  believed  to  be  in  total  abeyance.  Solid 
food  was  regarded  as  totally  inadmissible.  The  use 
of  stimulants  and  tonics  was  utterly  contrary  to  the 
antiphlogistic  regimen. 

In  the  course  of  the  eighteenth  century  and  down 
to  about  the  year  1815  the  antiphlogistic  treatment 
was  greatly  abated  in  rigor.  During  this  period  it 
began  to  be  appreciated  that  there  were  different  vari- 
eties of  the  continued  fevers,  such  as,  in  the  terms  of 
those  days,  inflammatory  fever  or  synocha,  typhus, 
putrid  fever,  nervous  fever,  synochus,  etc. ;  but  while, 
in  the  absence  of  knowledge  of  their  visceral  lesions, 
the  distinctions  drawn  between  these  varieties  were 
vague  and  dim,  yet  a  greater  discrimination  in  diagno- 


DIET  IN  TYPHOID   FEVER.  9 

sis  and  treatment  was  developing.  It  was  especially 
recognized  that  there  was  an  asthenic  or  adynamic 
element  involved  in  fevers  as  well  as  an  inflammatory 
or  phlogistic  element;  and  the  distinction  between  the 
two  was  regarded  as  of  vital  importance  in  treatment, 
since,  as  was  generally  agreed,  while  inflammatory  con- 
ditions required  vigorous  lowering  treatment,  the  ady- 
namic condition  required  stimulation.  There  was,  how- 
ever, difficulty  and  question  in  the  practical  applica- 
tion of  these  principles,  the  determination  whether 
particular  cases  or  diseases  were  essentially  inflamma- 
tory or  asthenic  arousing  almost  endless  spectdation 
and  discussion.  Many  for  instance,  held  that  the  ap- 
pearance of  asthenia  in  fevers  was  deceiving,  and  that 
the  symptoms  observed  were  really  due  to  over  excite- 
ment. In  the  treatment  of  the  continued  fevers  there 
were  thus  two  squarely  opposed  systems  of  practice, 
the  antiphlogistic  and  the  stimulant ;  the  advocates  of 
each  reproached  their  opponents  with  having  caused 
the  loss  of  untold  lives  by  their  vicious  methods,  and 
strenuous  controversies  were  waged  as  to  the  employ- 
ment of  bleeding,  purgatives,  emetics,  blisters,  food, 
tonics  (cinchona),  stimulants,  etc.  On  the  whole,  the 
antiphlogistic  habit  was  firmly  implanted  in  the  pro- 
fessional mind  and  strongly  influenced  the  practice 
even  of  those  who  did  not  concur  in  the  phlogistic 
theory  of  fevers. 

During  this  period  (down  to  about  1815)  the  mode 
of  treatment    of  continued  fevers  was  on  the  whole 


10  DIET   IN   TYPHOID   FEVER. 

stimulant  or  mildly  antiphlogistic,  the  adynamic  ele- 
ment being  freely  recognized.  Bleeding  and  other 
vigorous  depleting  measures  were  regarded  with  dis- 
favor, unless  at  the  very  onset  of  the  disease  or  in  dis- 
tinctly sthenic  cases  or  stages  of  fever.  What  was 
considered  a  liberal  amount  of  food  was  allowed, 
mainly  of  vegetable  character.  The  food  employed 
was  chiefly  farinaceous,  in  thin  liquid  or  pultaceous 
form,  as  gruels  or  ptisans  like  barley  water,  thin  oat- 
meal gruel,  sago  or  arrowroot  preparations,  and 
"  panada  "  (toast  water,  or  toast  made  into  a  fluid  mass 
with  boiling  water).  Fruit  juices  and  soft,  pulpy 
fruits  were  also  allowed.  What  was  regarded  as  a 
fairly  liberal  amount  of  such  vegetable  food  was  given, 
especially  after  the  first  few  days  of  the  fever.  Milk 
(especially  diluted  milk)  and  even  eggs  (Heberden) 
were  permitted,  with  caution  and  reserve,  by  some 
authorities.  Animal  food  was  in  general,  however, 
proscribed.  In  the  latter  period  of  the  fever  and  early 
convalescence  the  farinaceous  dietary  was  amplified  by 
the  addition  of  broths,  diluted  milk,  jellies,  and  gradual 
return  to  animal  food. 

Free  drinking  was  generally  encouraged  and  re- 
garded as  an  important  part  of  the  treatment,  to  dilute 
the  blood  and  promote  excretion.  Besides  plain  water, 
drinks  acidulated  with  lemon  or  currant  juice,  etc.,  or 
flavored  with  aromatics  or  otherwise,  were  in  high  fa- 
vor. Two  or  three  quarts  of  such  drinks  were  given 
daily.     In  the  eighteenth  century,  as   at  the  present 


DIET   IN   TYPHOID   FEVER.  11 

time,  there  were  some  who  carried  the  use  of  water  to 
an  extreme,  believing  in  the  sufficiency  of  an  aqueous 
diet,  that  is,  the  withdrawal  of  all  other  food  and  giv- 
ing water  in  large  amount,  four  quarts  or  so  daily. 

From  about  1815  to  1835  or  1840  continued  fevers 
were  again  treated  on  a  very  vigorous  antiphlogistic 
plan,  and  an  extremely  restricted  diet  was  in  general 
use. 

An  extensive  fever  epidemic  prevailed  in  Great 
Britain  and  Ireland  about  1817-1819,  during  which, 
largely  under  the  teachings  of  Clutterbuck,  Mills,  and 
others,  the  theory  that  fever  was  essentially  a  phlogis- 
tic or  inflammatory  process  came  into  general  favor, 
and  the  corresponding  practice  of  vigorous  depletion, 
chiefly  by  profuse  venesection,  was  generally  followed 
in  these  countries.  A  starvation  regimen  was  enforced ; 
the  drinking  of  watery  fluids  in  large  amounts  was  en- 
couraged, but  wine  and  stimulants  were  prohibited. 

In  France  the  adoption  of  antiphlogistic  practice 
during  this  period  was  due  to  the  teachings  of  Brous- 
sais  (1772-1838),  whose  writings  date  from  1816  and 
who  had  a  strong  influence  on  French  practice  for  a 
couple  of  decades.  Arguing  from  the  fact  that  ali- 
mentary disturbances  are  common  in  fevers  and  many 
other  disorders  (without  any  knowledge  of  the  intesti- 
nal lesions  in  typhoid),  he  taught  that  gastroenteritis 
was  the  primary  and  underlying  cause  and  essence  of 
manifold  disorders,  and  especially  of  the  various  fe- 
brile diseases.     So  firmly  did  this  idea  become  estab- 


12  DIET   IN   TYPHOID   FEVER. 

lished  that  for  a  considerable  period  the  term  "  gastro- 
enterite  "  was  one  of  the  principal  names  for  typhus 
and  typhoid  fevers.  The  treatment  of  fevers  practiced 
by  Broussais  and  his  followers  in  accordance  with  this 
conception  of  their  pathology  consisted  mainly  in  copi- 
ous withdrawal  of  blood  by  leeches  and  in  starvation. 
The  diet  allowed  —  the  "  diete  ahsolue  "  it  was  called 
—  was  practically  no  diet  at  all.  All  foods  requiring 
digestion  and  which  would  therefore  embarrass  the 
supposedly  inflamed  alimentary  tract, —  broths,  farina- 
ceous food,  fruits,  etc. —  were  prohibited,  broths  being 
regarded  as  especially  harmful.  All  that  was  allowed 
was  sufficient  drink  to  satisfy  thirst,  consisting  of 
slightly  sweetened  mucilaginous  drinks,  or  acidulated 
drinks  like  weak  lemonade,  gooseberry  or  raspberry 
water. 

The  next  epoch  in  the  history  of  typhoid  dietetics 
was  that  of  Graves  (1797-1853)  of  Dublin,  who  has  the 
reputation  of  having  established  the  practice  of  liberal 
feeding  in  fevers.  His  deliverances  covered  the  period 
from  about  1835-1850.  He  rejected  the  phlogistic 
theory  and  antiphlogistic  therapy  of  fevers,  and  be- 
lieved that  the  current  practice  needlessly  added  the 
"  horrible  consequences "  of  starvation  to  the  symp- 
toms of  the  fever,  and  that  it  was  "  as  hard  to  escape  the 
physician  as  the  disease.''  He  therefore  advocated 
what  he  regarded  as  liberal  feeding,  and  so  closely  is 
his  name  identified  with  this  practice  that  a  jocular 
suggestion  for  his  own  epitaph  —  "He  fed  fevers  " — 


DIET   IX   TTrHOID   FEVER.  13 

once  made  by  him,  has  become  historical.  This  inci- 
dent is  thus  related  by  Stokes,  the  associate  of  G-raves : 
"  Once,  when  he  and  I  were  going  through  the  conva- 
lescent wards,  he  expatiated  on  the  healthy  appear- 
ance of  the  patients,  many  of  whom  had  gone  through 
long  fevers.  '  This  is  all  owing  to  our  good  feeding,' 
he  said.  '  Will  you,  when  the  time  comes,  write  my 
epitaph,  and  let  it  be  —  He  fed  fevers?'"  As  a  mat- 
ter of  history,  it  may  be  stated  that  this  was  not 
actually  used  in  his  epitaph. 

The  diet  recommended  by  Graves  was  as  follows : 
For  the  first  three  or  four  days,  water,  weak  barley- 
water,  and  whey.  After  that  mild  nutriment  was  to  be 
used,  his  preference  being  for  well-boiled  gruel  made  of 
groats,  with  sugar  and  lemon  juice  ;  also  thin  panada. 
Of  the  gruel  and  panada  a  spoonful  of  either  was  given 
every  third  hour.  In  the  middle  and  late  stages  of  the 
fever  mild  animal  jellies  and  broths  (preferably  chick- 
en broth)  were  given.  Arrowroot  was  also  allowed. 
Fruits  were  to  be  avoided.  Food  was  to  be  given  in 
the  daytime  only  and  not  at  night.  Too  much  drink- 
ing was  not  permitted.  This  diet  was  much  the  same 
as  the  farinaceous  diet  used  in  the  eighteenth  century, 
which  was  therefore  reintroduced  by  Graves.  Judged 
by  present  dietetic  standards,  it  can  hardly  be  regarded 
as  a  very  generous  diet ;  and  if  it  was  considered  liberal 
in  Graves's  time,  the  dietary  previously  in  use  must 
have  been  scanty  indeed. 

It  was  during  the  latter  half  of  Graves's  life  that  the 


14  DIET  IN   TYPHOID   FEVER. 

true  pathology  of  typhoid  fever  was  discovered  and 
the  disease  came  to  be  recognized  as  a  distinct  affec- 
tion, di:fferent  from  typhus.  There  had  previously 
been  glimmerings  of  clinical  differences  between  dif- 
ferent kinds  of  continued  fevers,  as  in  Huxham's  dis- 
tinction between  "  slow  nervous  fever  "  (typhoid)  and 
"  putrid,  malignant,  petechial  fever  "  (typhus)  in  1750, 
and  the  synochus  and  typhus  of  Cullen  in  1769;  the 
intestinal  lesions  in  cases  of  typhoid  had  also  been 
observed  in  a  few  instances ;  but  the  morbid  anatomy 
of  typhoid  fever  was  first  put  on  a  substantial  and 
enduring  basis  by  Louis  (1787-1872),  whose  classical 
researches  on  this  subject  were  first  published  in  1829. 
The  continued  fevers  of  France  that  came  under 
Louis's  observation,  however,  were  exclusively  typhoid, 
and  not  having  had  a  chance  to  become  familiar  with 
typhus  he  did  not  realize  that  there  were  two  distinct 
diseases  and  he  regarded  the  lesions  observed  by  him 
as  pertaining  to  typhus.  In  America,  also,  the  prevail- 
ing fevers  were  mostly  typhoid ;  but  typhus  occasion- 
ally occurred,  and  it  was  through  an  opportunity  of 
observing  an  epidemic  of  the  latter  that  Gerhard  of 
Philadelphia,  who  had  become  familiar  with  typhoid 
in  Paris,  was  enabled,  in  1837,  to  announce  definitely 
that  typhoid  and  typhus  were  two  distinct  diseases. 
This,  the  first  clear  elucidation  of  the  distinctions 
between  these  two  diseases,  based  on  sound  pathologic 
principles,  stands  to  the  credit  of  American  medicine ; 
and  the  distinction  very  soon  became  generally  recog- 


DIET  IN   TYPHOID   FEVER.  15 

nized  in  the  United  States.  In  Great  Britain  and 
Ireland,  however,  the  prevaihng  fever  was  typhus, 
and  typhoid  was  so  exceptional  that  the  intestinal 
lesions  occasionally  seen  at  autopsy  and  described  by 
the  French  writers  were  regarded  as  secondary  and 
occasional  complications  of  typhus.  It  was  not  until  a 
series  of  papers  on  the  subject  was  presented  by  Sir 
William  Jenner,  in  1849-1851,  that  a  clear  understand- 
ing of  the  distinctions  between  typhoid  and  typhus 
was  finally  attained  by  British  physicians. 

The  recognition  of  the  distinct  character  and  intes- 
tinal lesions  of  typhoid  fever  at  first  had  no  influence 
on  the  dietetic  management  of  the  disease,  and  a  fari- 
naceous regimen  much  as  re-introduced  by  Graves  was 
generally  followed  down  to  the  late  sixties  and  the 
seventies  of  the  last  century.  The  medical  manuals 
of  this  period  specify  the  use  of  gruel,  arrowroot, 
panada,  and  similar  farinaceous  food,  with  refreshing 
drinks  flavored  with  fruit  juices,  for  typhoid  feeding. 
Some,  but  not  all,  of  the  writers  also  admitted  broths, 
jellies,  diluted  milk,  and  the  like.  As  late  as  1874, 
Liebermeister  argued  for  a  carbohydrate  or  farinaceous 
diet,  and  against  a  proteid  or  animal  diet,  on  much  the 
same  grounds  as  had  been  previously  adduced  for  cen- 
turies. 

During  the  seventies  of  the  ninteenth  century  milk 
came  into  practically  universal  use  as  the  main  and 
almost  exclusive  article  of  diet  for  typhoid  fever 
patients,  and  in  the  medical  manuals  since  1875   or 


16  DIET   IX   TYPHOID   FEVER. 

1880  the  milk  diet  has  been  almost  unanimously 
advocated.  There  appear  to  have  been  no  special 
papers  or  authorities  (except  possibl}^  the  teachings  of 
Austin  Flint)  that  led  to  the  abandonment  of  the  fari- 
naceous and  adoption  of  the  milk  regimen,  and  the 
change  was  brought  about  by  a  process  of  gradual 
evolution.     This  diet  has  been  in  vogue  ever  since. 

The  purpose  of  this  consideration  of  the  history  of 
typhoid  dietetics  has  been,  as  will  later  appear,  not  the 
mere  academic  one  of  presenting  the  history  of  defunct 
methods,  but  the  more  practical  one  of  attempting  to 
throw  real  light  on  this  important  question  b}^  endeav- 
oring to  trace  out  the  actual  worth  and  validity  of  the 
grounds  on  which  the  present  methods  have  been 
developed. 

PRESEXT    DIETETIC    METHODS    IX    TYPHOID    FEVER. 

At  the  present  time  a  diet  consisting  chiefly  of  milk, 
with  broths  and  similar  fluids  as  accessories, —  the  so- 
called  "  hquid  diet," —  is  almost  universally  employed 
in  typhoid  fever.  The  firmest  faith  and  confidence  in 
the  adequacy  and  superiority  of  this  diet  are  enter- 
tained; it  is  by  the  great  majority  of  practitioners 
enforced  unvaryingly,  indiscriminately,  and  mechani- 
cally in  all  cases  of  the  disease ;  and  the  gravest  fears 
are  held  of  departures  from  it,  or  of  the  use  of  solid 
or  even  of  soft  food.  So  firm  and  fixed  are  the  general 
convictions  on  this  doctrine  that  it  is  regarded  as  im- 
pregnable, final,  and  beyond  question;  it  has  attained 


DIET   IN   TYPHOID   FEVER.  17 

almost  the  sanctity  of  a  creed,   and  dissent  from  it  is 
viewed  as  folly  or  heresy. 

There  are,  nevertheless,  not  wanting  a  few  who 
venture  to  question  the  entire  superiority  and  efficacy 
of  the  present  dietetic  methods  in  this  disease  ;  some, 
on  the  one  hand,  advocating  a  return  in  more  or  less 
degree  to  the  old  starvation  system ;  others  urging  a 
more  liberal  and  more  varied  diet  than  that  usually 
given.  In  the  discussion  of  this  subject  there  are, 
therefore,  three  contrary  dietetic  systems  to  be  taken 
into  consideration,  the  starvation  regimen,  the  milk  or 
"liquid  "  diet,  and  the  liberal  and  varied  diet.  At  the 
very  outset  we  are  confronted  with  the  fundamental 
question,  should  typhoid  patients  be  starved,  or  should 
they  be  liberally  fed  and  nourished?  In  order  satis- 
factorily to  elaborate  the  subject  of  the  diet  in  typhoid 
fever  it  will  be  necessary  to  consider  the  grounds  of 
the  different  dietetic  systems  in  the  field  and  to  deter- 
mine the  fundamental  guiding  principles  on  which  the 
dietetic  management  of  typhoid  fever  can  be  rationally 
and  firmly  established, 

THE  STARVATION"  TREATMENT  OF  TYPHOID  FEVER. 

The  old  antiphlogistic  arguments  for  starvation  in 
fever  are  now  obsolete.  The  arguments  advanced  by 
recent  writers  against  feeding  are  various. 

One  writer  would  withhold  all  food  in  the  early 
period,  in  order  to  arouse  the  patient's  hunger,  claim- 
ing that  when  that  is  evoked  the  symptoms  will  sub- 


18  DIET   IN   TYPHOID   FEVER. 

side  and  the  disease  can  be  thus  aborted.  Another 
authority  advocates  withholding  proteid  food  in  the 
early  part  of  the  disease,  so  that,  by  intensifying  pro- 
teid starvation,  when  the  capacity  for  regenerating  the 
nitrogenous  tissues  returns  proteid  food  will  then  be 
taken  up  with  greater  avidity,  and  convalescence  pro- 
ceed more  rapidly ;  forgetting  that  the  less  there  is 
lost  the  less  there  is  to  regain. 

Several  writers  urge  the  withholding  of  other  food 
and  the  administration  of  large  amounts  of  water  as 
practically  the  sole  diet  in  typhoid  fever ;  some  extrem- 
ists have  advocated  the  giving  of  excessive  amounts, 
up  to  6  or  7  liters  daily,  not  only  by  the  mouth,  but 
also  by  the  rectum,  by  hypodermoclysis,  and  even  in- 
travenously. The  advocates  of  the  water  diet  argue 
that  water  is  the  principal  element  of  food  and  claim 
that  it  alone  is  a  .sufficient  diet  for  typhoid  patients. 
It  requires  but  the  slightest  consideration,  however,  to 
see  that  such  a  diet  necessarily  results  in  starvation  as 
to  the  proteid  and  other  essential  food  elements  that 
are  withheld. 

Another  objection  to  milk  and  other  foods  besides 
water  is  that  they  afford  a  culture  medium  in  the 
bowel  for  bacterial  growth  and  toxin  production ;  but 
food  always  does  that,  and  in  typhoid  fever  the  seat  of 
the  toxin-generating  bacterial  growth  that  does  the 
harm  is  in  the  tissues,  not  in  the  lumen  of  the  bowel. 
Even  in  the  fasting  condition  there  is  always  an  abun- 
dance of  fecal  debris  in  the  bowel,  derived  from  intes- 


DIET   IN    TYPHOID   FEVER.  19 

tinal  cells  and  secretions,  amply  sufficient  for  bacterial 
growth.  The  supposed  impairment  of  the  digestive 
powers,  the  disadvantage  of  fermentation,  and  the 
possibility  of  overloading  or  clogging  the  circulation 
with  metabolic  material,  are  also  advanced  as  reasons 
for  withholding  all  food  in  this  disease.  Some,  seeing 
the  objections  to  milk,  and  not  conceiving  the  possibil- 
ity of  giving  other  articles  of  diet,  would  withhold  all 
food  except  water.  It  might  also  be  argued  that  as 
typhoid  fever  attacks  by  preference  healthy  and 
robust  individuals,  the  bacilli  finding  that  kind  of  soil 
most  favorable  for  their  growth,  the  wasting  and  en- 
feebling of  the  patients  is  a  sort  of  effort  of  nature  to 
impoverish  the  soil  so  as  to  stop  the  growth  of  the 
bacilli ;  and  that  a  starvation  regimen  would  promote 
that  result. 

Again,  the  results  of  clinical  experience  are  appealed 
to  in  support  of  the  claimed  utility  of  the  starvation 
treatment.  Series  of  cases  so  treated,  with  low  mor- 
tality, are  reported.  Typhoid  patients  as  a  matter  of 
fact  often  maintain  a  surprisingly  good  grade  of  general 
body  nutrition  for  comparatively  long  periods  under 
starvation  conditions ;  and  eminent  authorities,  of  wide 
experience,  have  expressed  the  opinion  or  impression 
that  they  will  actually  do  better  on  an  insufficient 
diet.  As  to  this  point  it  must  be  remembered  that 
the  normal  human  body  can  exist  and  nutrition  be 
maintained  for  several  weeks  without  auy  food  what- 
ever, except  water,  being  taken ;  and  the  maintenance 


20  DIET   IN   TYPHOID   FEVER. 

of  tjphoid-fever  patients  under  such  conditions  de- 
pends on  the  utiliHzation  of  the  reserve  material 
afforded  by  the  body  tissues.  It  by  no  means  follows 
that,  because  nutrition  can  for  considerable  periods  be 
comparatively  well  maintained  in  typhoid  patients  on 
a  starvation  basis,  that  regimen  is  therefore  beneficial 
to  the  patients.  No  one  would  contend  that  absti- 
nence from  food  by  a  healthy  person  for  four  or  five 
weeks  would  be  beneficial,  or  would  result  in  anything 
but  harm  to  nutrition  and  impairment  of  body  func- 
tions and  activities.  It  is  equally  illogical  to  suppose 
that  starvation  could  of  itself  benefit  a  typhoid  patient. 
If  it  is  harmful  to  a  well  person,  it  would  be  far  more 
injurious  to  an  ill  person;  if  typhoid-fever  patients  do 
well  under  a  starvation  regimen,  it  is  not  because  of 
that  regimen  but  in  spite  of  it.  As  for  the  idea  fre- 
quently expressed  that  the  feats  of  Tanner  and  others 
who  fasted  for  long  periods  on  nothing  but  water  can 
serve  in  any  way  as  a  precedent  for  the  management 
of  typhoid  patients,  it  should  be  remembered  that 
these  fasts  were  tests  of  endurance  for  strong,  healthy 
men,  which  brought  them  to  the  verge  of  fatality ; 
and  it  would  be  as  reasonable  to  expect  a  typhoid 
patient  to  undertake  them  as  to  engage  in  a  football 
game  or  a  century  bicycle  run. 

The  writer  is  convinced  that  all  the  arguments  ad- 
vanced in  favor  of  starvation  in  typhoid  fever  are 
fallacious  and  untenable.  The  starvation  regimen  is 
utterly   contrary    to    all   recognized   physiologic    and 


DIET   IN   TYPHOID    FEVER.  21 

dietetic  principles.  During  the  long  antiphlogistic 
era  the  system  was  given  a  universal  trial,  lasting  for 
centuries;  and  the  sweeping  condemnation  passed 
upon  it  by  the  entire  medical  profession,  after  a  world- 
wide observation  of  its  effects,  may  be  accepted  as 
final.  The  sporadic  attempts  to  revive  a  practice  that 
belonged  to  the  dark  ages  of  medicine  can  but  be 
regarded  as  atavistic  recrudescences  of  medieval  error 
and  unenlightenment. 

THE    MILK    OR    "  LIQUID  "    DIET    IN    TYPHOID    FEVER. 

At  present  the  nearly  universal  practice  is  to  limit 
the  diet  of  typhoid-fever  patients  to  milk,  with  broth, 
—  so-called  "  liquid  "  diet,  —  while  solid  and  even  soft 
foods  are  rigidly  excluded  and  regarded  as  highly 
injurious  and  dangerous.  Various  arguments  are  pre- 
sented in  favor  of  this  practice. 

A  characteristic  example  of  the  way  in  which  the 
subject  is  usually  presented,  and  one  embodying  most 
of  the  points  involved,  is  afforded  by  the  following 
passage  from  Hutchinson's  article  on  typhoid  fever  in 
1885  :  "  The  food  must  ...  be  not  only  nourishing, 
but  also  readily  digestible,  and  not  likely  to  create 
irritation  in  its  passage  through  the  intestine.  All 
solid  food  should  therefore  be  excluded  from  the  diet- 
ary of  the  patient  as  long  as  the  fever  lasts.  .  .  .  Milk 
as  an  article  of  diet  is  unquestionably  to  be  preferred 
to  all  others  in  typhoid  fever." 


22  DIET   IN   TYPHOID   FEVEK. 

Under  the  practice  now  prevalent  typhoid  patients 
generally  receive  about  1|  to  2  liters  (3  to  4  pints)  of 
milk  daily,  or  its  equivalent.  These  amounts  of  milk 
yield  about  1,000  to  1,300  calories  of  energy,  and  50  to 
70  grams  of  proteid  (8  to  11  grams  of  nitrogen) ;  these 
figures  may  be  accepted  as  representing  the  approxi- 
mate daily  nutritive  standard  of  the  present  typhoid 
dietary. 

The  general  premises  that  the  typhoid  diet  should 
be  nutritious,  digestible,  and  innocuous  are  generally 
agreed  on.  But  whether  the  current  dietary  com- 
pletely fulfills  these  premises  has  been  contested.  The 
inadmissibility  of  solid  food  and  the  intrinsic  superior- 
ity of  milk  are  not  self-e\ddent ;  the  conclusions  on  this 
point  brought  out  in  the  average  statements  of  the 
subject  made  in  the  current  manuals  of  medicine  (as 
exemplified  in  the  above  quotation  from  Hutchinson) 
do  not  necessarily  and  obviously  follow  from  the  prem- 
ises as  stated.  The  superiority  of  the  present  dietetic 
method  should  be  established,  not  on  vague  impressions 
or  dogmatic  assumptions,  but  on  a  rational  analysis  of 
the  physiologic  and  dietetic  factors  involved,  as  checked 
by  the  results  of  adequate  experience.  The  milk  diet 
has  not  (so  far  as  known)  been  subjected  to  or  based 
on  that  scientific  critique  and  analysis  which  its  impor- 
tance demands  or  which  would  warrant  the  firm  faith 
generally  entertained  as  to  its  efficacy  and  superiority. 

The  present  milk  dietary  has  been  assailed  on  vari- 
ous grounds,   such  as :   that  it  does  not  supply  suffi- 


DIET   IN   TYPHOID   FEVER.  23 

cient  nutriment ;  that  milk  is  not  the  most  digestible 
of  foods ;  that  milk  is  unusually  productive  of  intesti- 
nal indigestion  and  more  apt  to  cause  intestinal  injury 
than  many  other  foods ;  that  soft  and  solid  food  are 
much  more  digestible  and  much  less  harmful  in 
typhoid  fever  than  has  been  generally  supposed  ;  that 
even  if  solid  food  were  contraindicated,  milk  (which 
immediately  coagulates  in  the  stomach  and  may  pass 
through  the  intestine  in  solid  curds)  is  far  from  being 
a  really  liquid  food ;  and  that  the  results  of  clinical 
experience,  when  fairly  interpreted,  do  not  support  the 
contention  for  the  exclusive  use  of  milk  and  the  ex- 
clusion of  other  articles. 


THE  LIBEEAJL  AND  VARIED  DIET  IN  TYPHOID  FEVER. 

There  are  a  few  of  the  medical  profession  who,  in 
spite  of  the  censure  they  thereby  incur,  venture  to  dis- 
sent from  the  doctrines  firmly  held  by  the  generality 
of  the  profession  as  to  the  superiority  and  finality  of 
the  milk  diet  and  the  inadmissibility  of  other  food. 
They  hold  that  the  prevalent  milk  diet,  while  far  better 
than  a  deliberate  starvation  regimen,  is  still  insuffi- 
cient for  adequate  nutrition,  and  should  and  safely  can 
be  amplified  by  the  addition  of  other  articles ;  that  the 
dangers  of  soft  and  solid  food  are  largely  mythical  and 
have  been  greatly  overestimated ;  and  follow  in  gen- 
eral along  such  grounds  as  are  pointed  out  in  the  pre- 
ceding paragraph.      They  advocate   and    use    a  diet 


24  DIET   IN   TYPHOID   FEVER. 

more  liberal  and  varied  than  that  in  general  use,  in- 
cluding not  only  soft  food  like  eggs,  puddings,  cereals, 
etc.,  but  even  meat  (when  needed).  The  adherents  of 
liberal  mixed  feeding  in  typhoid  fever,  while  compara- 
tively few  in  number,  are  apparently  increasing ;  they 
are  found  in  all  parts  of  the  world,  and  include  among 
their  numbers  some  authorities  of  the  highest  eminence. 
The  points  involved  between  the  milk  diet  and  the 
mixed  diet  will  be  developed  and  considered  in  detail 
in  the  course  of  the  present  discussion. 

BASIC  PRINCIPLES. 

With  the  exception  of  the  few  adherents  of  a  defi- 
nite starvation  therapy  the  profession  is  professedly 
practically  unanimous  in  favor  of  feeding  typhoid  fever 
patients.  The  arguments  in  favor  of  liberal  feeding 
are  cogent.  Insufficient  nourishment  during  so  long  a 
period  as  that  covered  by  typhoid  fever  will  necessa- 
rily add  the  symptoms  of  starvation  to  the  already  bad 
enough  symptoms  of  the  disease,  and  make  the  typhoid 
state  far  more  typhoid.  It  is  plainly  advisable  to  elim- 
inate starvation  effects  from  the  symptom-complex. 
It  would  also  seem  reasonable  that  the  maintenance  of 
the  patient's  strength  and  nutrition  at  the  highest 
point  possible  would  increase  and  promote  the  resist- 
ant, reactive,  and  recuperative  powers  of  the  system 
against  the  disease;  just  as  tuberculous  and  septic 
patients  are  now  fed  to  the  highest  limit  as  part  of  the 
contest  against  the  infectious  process. 


DIET   IN   TYPHOID   FEVEK.  25 

From  these  considerations,  and  others  which  may 
appear  in  the  course  of  this  discussion,  in  this  study  is 
adopted  as  the  guiding  principle  in  the  dietetic  man- 
agement of  typhoid  fever  the  proposition  that  — 

Tyijhoid-fevei^  IKitients  should  he  fed  and  nourished  as 
liberally  as  is  possible,  within  the  limits  of  their  capacity 
for    digestion,  and  avoiding  special  harmfid  effects. 

The  proposition  thus  stated  will,  it  is  believed,  be 
assented  to  by  nearly  all ;  and  without  anticipation  or 
prejudgment  of  the  conclusions  to  be  arrived  at  will 
serve  as  a  basic  principle  upon  which  and  from  which 
the  subject  can  be  rationally  elaborated. 

There  is  nothing  occult  or  esoteric  in  the  subject  of 
the  dietetics  of  typhoid  fever.  The  organism  affected 
with  this  disease  must  manifest  definite  physiologic 
processes  and  laws  of  nutrition  and  metabolism ;  and 
the  attempt  of  the  ensuing  discussion  will  be  the 
elucidation  of  those  processes  and  laws  by  means  of 
methods  and  data  analogous  to  those  employed  in  the 
establishment  of  the  principles  of  scientific  dietetics  in 
health  and  in  general.  In  addition  to  working  out 
the  theory  of  typhoid  dietetics,  the  results  of  actual 
practice  will  be  presented  and  their  correlation  with 
the  theory  brought  out. 

ESSENTIAL  EEQUIKEMENTS  OF  TYPHOID-FEYER  DIET. 

Having  formulated  the  forgoing  principle  for  guid- 
ance, it  next  becomes  necessary  to  determine  and  es- 
tablish   the    essential   requirements   for   the    diet   in 


26  DIET   IN   TYPHOID   FEVER. 

typhoid  fever.  These  requirements  can  be  grouped 
under  four  heads  —  nutritive  value,  digestibility,  pala- 
tability,  and  innocuousness. 

NUTEITIVE  EEQUIEEMENTS  IN  TYPHOID  FEVER. 

With  regard  to  to  the  nutritive  value  requisite  in 
an  adequate  typhoid  fever  diet  we  have  to  consider  the 
total  energy  needed  and  the  amounts  required  of  pro- 
teid,  fat,  carbohydrate,  and  water.  The  elaboration  of 
these  points  involves  the  question  of  metabolism  in 
typhoid  fever,—  the  metabolism  of  matter  and  the  me- 
tabolism of  energy. 

Metabolism  of  matter. — The  most  striking  and  ob- 
vious fact  in  the  metabolism  of  typhoid  fever  is  the 
constant  metabolic  balance  against  the  body,  that  is, 
the  continuous  net  loss  of  body  tissue,  as  manifested 
in  the  progressive  decrease  in  weight.  Under  ideal 
normal  conditions,  the  tissue  losses  of  the  body  are  en- 
tirely replaced  from  the  food.  During  the  pyrexia  of 
typhoid  fever,  however,  there  is  necessarily  a  greater 
destruction  of  body  tissue  than  can  be  made  good  by 
the  food.  It  has  been  found  that  (excepting  in  occa- 
sional cases  for  brief  periods)  no  matter  how  much  the 
food  is  increased,  the  destruction  of  body  tissue  con- 
tinues to  keep  in  excess;  there  is  a  constant  balance 
against  the  body,  and  a  certain  amount  of  emaciation 
seems  to  be  inevitable  with  the  most  favorable  diet. 

The  average  loss  of  weight  of  typhoid  patients  during 
the  febrile  period  ranges  ordinarily  from  about  200  to 


DIET   IN   TYPHOID   FEVER.  27 

600  grams  (7  to  20  ounces)  daily,  or  about  0.3  to  1.0  per 
cent  of  the  body  weight.  In  57  of  the  cases  summar- 
ized in  Table  I  the  average  daily  loss  of  weight  dur- 
ing pyrexia  was  about  320  grams,  or  0.59  per  cent  of 
the  body  weight.  Different  subjects  show  great  in- 
dividual differences  in  their  changes  of  weight  in  ty- 
phoid fever ;  occasionally  for  brief  periods  a  patient 
may  maintain  or  even  gain  weight  on  a  small  diet  dur- 
ing the  febrile  period.  Weight  observations  are  not 
often  made  on  typhoid  patients  during  the  course  of 
the  disease ;  so  that  a  close  approximation  to  the 
average  changes  in  weight  in  these  cases,  or  a  reliable 
basis  for  comparisons,  can  not  be  made  from  the  data 
now  available.  A  few  investigators  present  results  in- 
dicating that  the  amount  of  food  given  governs  to  some 
degree  the  extent  of  loss  of  weight;  and  while  the 
figures  of  different  observers  do  not  always  show 
marked  agreement,  there  can  be  no  doubt  that  in  gen- 
eral less  emaciation  is  to  be  expected  with  generous 
feeding.  Under  these  circumstances,  one  fundamental 
principle  should  obviously  be  that  the  diet  in  typhoid 
fever  should  be  of  such  amount ,  other  things  being 
equal,  as  to  reduce  the  inevitable  loss  of  body  weight 
to  the  minimum. 

This  loss  of  weight  comes  from  losses  of  the  nitro- 
genous and  fatty  tissues  of  the  body,  and  of  the  water 
in  these  tissues. 

The  loss  of  nitrogenous  tissue  is  easily  determinable 
from  nitrogen  analyses  of  the  food,  urine,  and  feces, 


28 


DIET   IN   TYPHOID   FEVER. 


and  computation  of  the  nitrogenous  exchanges  and 
metaboHsm.  With  an  adequate  diet,  as  discussed 
below,  the  average  loss  of  protein  or  nitrogenous  body 
substance  can  probably  be  brought  down  to  about  30 
grams  daily,  or  less. 

The  exact  loss  of  body  fat  and  water  can  not  be  de- 
termined except  by  elaborate  tests  in  the  respiration 
chamber.  The  largest  part  of  the  total  loss  of  body 
weight,  probably  two  thirds  or  more,  is  made  up  of 
water.  It  has  been  generally  held  that  the  amount  of 
body  fat  consumed  in  typhoid  fever  is  comparatively 
small,  that  is,  less  in  proportion  to  the  loss  (»f  protein 
than  occurs  in  ordinary  starvation.  A  general  estimate 
of  fat  loss  is  afforded  by  the  respiratory  quotient,  a  low 
quotient  in  general  indicating  a  large  oxidation  of  fat, 
a  high  quotient  a  predominant  oxidation  of  carbohy- 
drate, while  the  oxidation  of  protein  yields  a  medium 
quotient.  Such  respiratory  observations  as  have  been 
made  in  cases  of  typhoid  fever  indicate  a  low  respira- 
tory quotient  during  the  febrile  period,  as  shown  in  the 
following  summary  : 


Intestigator. 

No.  OF  Cases. 

AVEEAGE  RESPIBATOBT 

Quotient. 

Regnard , 

7 
4 
2 
3 
5 

21 

.65 

Kraus 

.81 

.68 

Robin  and  Binet 

.73 

Riethus 

.67 

General  average... 

.70 

DIET   m   TYPHOID   FEVER.  29 

The  low  respiratory  quotient  of  .70  would  indicate  a 
relatively  large  oxidation  of  fat.  In  the  fasting  exper- 
iments conducted  by  Atwater  on  a  healthy  subject,  at 
rest,  in  the  respiration  calorimeter,  the  ratio  of  body 
protein  to  fat  lost  was  1:2.42,  with  a  respiratory  quo- 
tient of  .73.  We  might  therefore  assume  that  during 
the  febrile  period  of  typhoid  fever,  with  a  similar  low 
quotient,  the  loss  of  body  fat  would  probably  be  at 
least  double  the  loss  of  bod}^  protein.  A  daily  loss  of 
30  grams  of  body  protein,  70  grams  of  body  fat,  and 
200  grams  of  body  water  would  therefore  account  for  a 
total  daily  loss  of  body  weight  of  300  grams. 

During  convalescence  the  power  of  the  tissues  to  re- 
generate is  restored,  and  they  greedily  utilize  and 
retain  the  food  material  offered. 

Metcibolisvi  of  energy :  Unfortunately,  in  the  lack 
of  accurate  and  reliable  respiratory  and  calorimetric 
investigations  on  human  subjects,  our  ideas  of  the  oxy- 
gen intake,  carbon-dioxid  output,  and  energy  metabol- 
ism in  fever  are  very  vague.  On  superficial  view  it 
would  seem  that  in  fever  there  would  be  a  total  increase 
of  oxidation  and  energy  output;  but  this  is  by  no 
means  certain,  and  some  investigations  seem  to  have 
shown  a  decrease  rather  than  an  increase.  The  one 
essential  point  about  energy  metabolism  in  fever  is 
that  heat  dissipation  is  relatively  lowered  as  compared 
with  heat  production ;  but  this  indicates  nothing  as  to 
the  absolute  amount  of  heat  exchanges,  and  both  heat 
formation    and   heat  output  through  the  twenty-four 


30  DIET   IN   TYPHOID   FEVEK. 

hours  could  be  less  than  normal  compatibly  with  the 
febrile  condition. 

The  recorded  respiratory  investigations  in  cases  of 
typhoid  fever  *  are  all  made  by  comparatively  imper- 
fect methods,  and  yield  no  marked  or  certain  results. 
Experiments,  more  satisfactory  on  animals  have 
shown  an  increase  of  oxidation  in  fever,  and  it  is  the 
general  impression  of  the  authorities  on  the  subject 
that  in  fever  the  consumption  of  oxygen,  output  of 
carbon  dioxide,  and  energy  eliminated  are  ordinarily 
about  5  to  16  per  cent  more  than  in  health  at  rest; 
still  more  when  the  cardiac  and  respiratory  activities 
are  greatly  accelerated.  Exact  determinations  of  the 
increase,  which  are  greatly  needed,  would  require  the 
use  of  the  respiration  calorimeter. 

Total  energy :  In  the  lack  of  such  observations  we 
can  derive  an  estimate  of  the  total  energy  or  caloric 
value  required  in  the  typhoid-fever  diet  only  in  an  in- 
direct and  tentative  way.  The  physical  situation  of  a 
typhoid  fever  patient  is  the  same  as  that  of  a  person 
at  rest,  and  we  may  adopt  as  the  standard  of  nutrition 
that  of  a  healthy  resting  person,  with  such  modifica- 
tions as  are  imposed  by  the  conditions  of  the  disease. 

The  daily  metabolism  of  total  energy  in  a  normal 
adult  at  rest  is  about  33  kilocalories  per  kilogram  (15 
calories  per   pound)  of  body-weight,   or  about  2,300 


*  Respiratory  investigations  in  cases  of  typhoid  fever  liave  been  made  by  Schroeder 
(1869),  Liebermeister  (1872),  Buss  (1878),  Regnard  (1878),  Wertheim  (1878,  1882),  Kraus 
(1890),  Loewy  (1891),  Robin  and  Binet  (1896),  and  Riethus  (1900). 


DIET   IN   TYPHOID   FEVEE.  31 

calories  daily  for  a  person  weighing  70  kilos  (154 
pounds).  If  in  the  febrile  condition  there  is  an  aug- 
mentation of  the  heat  elimination  of  13  per  cent  (Von 
Noorden),  this  would  increase  the  energy  metabolism 
by  300  calories,  making  2,600  calories  as  an  approxi- 
mate estimate  of  the  daily  energy  output  in  typhoid 
fever. 

This  energy  evolved  is  derived  from  the  katabolism 
of  food  material  and  body  tissue.  Under  ideal  condi- 
tions the  energy  output  of  the  body  is  supplied  entirely 
by  the  food.  This  output  is  mainly  independent  of  the 
amount  of  food  taken  ;  and  if  the  food  is  not  sufficient 
to  yield  all  the  energy  required  for  carrying  on  the 
body  activities,  enough  body  tissue  will  be  burned  in 
addition  to  supply  the  remainder  of  the  energy  needed. 

In  typhoid  fever,  as  noted  above,  however  liberal 
the  diet  may  be,  a  certain  amount  of  the  body  tissues 
will  inevitably  be  consumed  in  excess  of  the  food 
supply.  This  inevitable  oxidation  of  body  tissue  will 
furnish  a  part  of  the  total  energy  required  by  the  or- 
ganism ;  the  remainder  must  be  supplied  by  the  food, 
and  the  diet  should  be  sufficient  in  amount  to  reduce 
consumption  of  body  substance  to  the  minimum. 

Supposing  the  body  loss  to  be  reducible  to  30  grams 
of  protein  and  70  grams  of  fat  daily,  the  oxidation  of 
these  amounts  of  these  materials  would  afford  about 
800  calories  of  energy.  Deducting  this  800  from  the 
total  energy  requirement  of  2,600  calories  leaves  us 
1,800  calories  to  be  supplied  by  the  food.     While  there 


32  DIET   IN   TYPHOID   FEVEK. 

are  some  uncertain  and  variable  elements  in  this  com- 
putation, with  our  present  data  we  may  tentatively 
accept  1,800  calories  as  a  moderate  estimate  (subject 
to  future  revision)  of  the  daily  amount  of  energy  which 
should  be  supplied  by  the  diet,  to  a  person  of  70  kilos 
weight,  during  the  febrile  period  of  typhoid  fever. 

During  convalescence  the  requirement  is  much 
greater,  and  the  food  should  then  be  sufficient  not  only 
to  jdeld  the  2,300  calories  required  by  the  organism  at 
rest,  but  also  to  supply  the  material  being  stored  up 
in  the  body  tissues. 

The  energy  required  can  be  distributed  ad  libitum 
among  the  proteid,  carbohydrate,  and  fatty  elements 
of  the  food,  provided  that  a  certain  minimum  amount 
of  proteid  necessary  for  nitrogenous  metabolism  is  sup- 
plied. The  coefficients  by  which  the  energy  value  of 
the  different  kinds  of  food  can  be  computed  are,  for 
each  gram  of 

Protein 4.1  calories 

Carbohydrate 4. 1        " 

Fat ,...9.3       " 

Alcohol 7.1 

Proteid  and  nitrogen :  The  nitrogenous  equilibrium 
which  the  organism  tends  to  maintain  in  health  is  pro- 
foundly disturbed  during  typhoid  fever.  In  this  con- 
dition the  destruction  of  protein  and  elimination  of  ni- 
trogen during  the  pyrexia  is  practically  always  much 
in  excess  of  that  introduced  in  the  food ;  and  it  is  prac- 
tically impossible  by  increasing  the  nitrogenous  ele- 


DIET   IN   TYPHOID   FEVER.  33 

ments  of  the  food  to  make  good  the  deficit  and  attain 
a  nitrogen  balance.  This  is  due  to  destruction  of  the 
protoplasm  of  the  body  cells  by  the  typhoid  toxins 
in  excess  of  their  capacity  for  regeneration.  Since  it 
is  impossible  to  attain  the  ideal  result  of  giving  a  pro- 
tein ration  sufficient  to  meet  the  protein  loss,  it  seems 
obvious  that  the  amount  of  protein  food  given  should 
be  such  as  will  reduce  the  drain  on  the  tissue  proteids 
and  the  net  nitrogenous  loss  to  a  minim  am. 

In  order  to  determine  this  optimum  proteid  ration 
and  as  an  exhibit  of  nitrogenous  metabolism  in  typhoid 
fever,  I  have  prepared  from  all  published  reports  of 
metabolism  investigations  in  this  condition  *  the  accom- 
panying Table  I,  showing  the  average  daily  nitrogen- 
ous exchanges  during  both  the  febrile  and  convales- 
cent periods.  This  table  presents  the  results  of  215 
metabolism  observations,  made  by  approved  methods 
in  81  cases  of  typhoid  fever  by  20  different  observers, 
and  covering  a  total  of  974  days  of  investigation. 


*  Studies  of  nitrogen  metabolism  in  typhoid  fever  have  been  made  by  Renk  (1877), 
Bauer  and  Kijnstle  (1879),  Hoesslin  (1882),  Miiller  (1884),  Engel  (1885),  Riess  (1886-'87), 
Walter (1886),  Khadgi  (1888),  Aikanov  (1889),  Muller(1889),  Diakonov  (1890),  Matzkevich 
(1890),  Grammatchikov (1890),  Gruzdiev(1890),  Geisler  (1890),  Puritz  (1892),  DUnschmann 
(1892),  vt)n  Leyden  and  Klemperer  (1898-'99),  Ladenburger  (1901),  and  Mohr  (1904). 


34 


DIET   IjST   typhoid   FEVER. 


TABLE  I.     AvEBAGE  Daily  Nitrogenous  Metabolism  a»d 
Exchanges  in  Typhoid  Fever. 


Observations     in 
which   the  amount 
of  nitrogen  in  the 
dally  ration  was  :— 

i 

O 
u 

a 

CM   ^ 

11 
^1 

.2    S 

Nitrogen 
ingested 
in  food. 

c  © 

Nitrogen 
digested 

and 
absorbed. 

Per    cent   of 
j  food  nitrogen 
digested  and 
absorbed. 

a  6 
gc-S 
2£ 

Nitrogen 
loss  (— )  or 
gain  (+). 

IZi 

15 

Days. 

Grams. 

Grams. 

Grams . 

jrer 
cent. 

Grams. 

Grams. 

During  pyrexia: 
0  to    8.9  grams 

11 

50 

1.9 

.8 

1.1 

57.9 

13.1 

-12.0 

4  to    7.9       " 

29 

58 

218 

6.6 

1.7 

4.9 

74.2 

14.8 

-  9.9 

8  to  11.9       " 

30 

36 

173 

9.3 

1.3 

8.0 

86.0 

15.8 

-7.8 

12  to  15.9       " 

23 

40 

154 

14.3 

2.0 

12.3 

86.0 

20.4 

-  8.1 

16  to  19.9       '' 

7 

11 

34 

17.7 

2.1 

15.6 

88.1 

19.3 

-3.7 

20  to  2.3.9       " 

8 

9 

64 

22.0 

3.3 

18.7 

85.0 

25.2 

-  6.5 

24  to  27.9       " 

5 

5 

53 

25.3 

3.0 

22.3 

88.1 

26.9 

-  4.6 

Over  28 

3 
79 

4 

178 

20 

34.3 

5.5 

28.8 

84.0 

42.0 

-18.2 

General  average.. 

766 

11.1 

1.9 

9.2 

82.9 

17.8 

-  8.6 

During  convales- 

cence: 

Under  15  grams 

18 

16 

83 

10.4 

1.1 

9.3 

89.4 

18.6 

-  4.3 

Over     15  grams 

21 

22 

125 

24.0 

8.0 

21. 0 

87.5 

17.7 

+3.3 

Average  weight  of  57  of  the  subjects  (126  experiments),  during  the 
pyrexia,  54.2  kgms;  average  daily  loss  of  weight  .32  kgm.,  or  0.59  per 
cent  of  the  body  weight. 


In  this  table  the  observations  are  classed  and  aver- 
aged in  groups,  according  to  the  amount  of  nitrogen 
in  the  daily  ration.  The  figures  in  the  last  column 
show  that  the  daily  nitrogen  loss,  or  excess  of  nitrogen 
outgo  over  nitrogen  income,  decreases  from  the  smal- 
lest ration  to  a  ration  of  16  to  20  grams,  remains  quite 
low  with  a  nitrogen  ration  of  20  to  28  grams,  and 
over  that  amount  again  markedly  increases.  While  a 
greater  number  of  experiments  with  the  ampler  diets 


DIET  IN  TYPHOID   FEVER.  35 

are  desirable  to  settle  the  point  well,  the  data  at  hand 
indicate  that  a  daily  ration  containing  from  16  to  20 
grams  of  nitrogen,  averaging  about  17.7  grams,  reduces 
the  nitrogen  waste  to  a  minimum  and  would  seem  the 
optimum  amount  for  typhoid  diet.  As  proteid  sub- 
stances contain  an  average  of  about  16  per  cent  of 
nitrogen,  17.7  grams  of  nitrogen  would  be  equivalent 
to  about  110  grams  of  protein. 

The  amount  of  protein  as  thus  determined  agrees 
very  closely  with  the  amount  generally  recognized  as 
daily  required  for  the  maintenance  of  nitrogenous 
metabolism  at  rest  in  health,  namely,  about  1.5  grams 
per  kilo  of  body-weight,  which  with  a  person  weighing 
70  kilos  would  amount  to  105  grams  of  protein  daily. 

As  for  the  contention  of  Chittenden  of  the  adequacy 
of  a  proteid  ration  far  below  that  generally  regarded 
as  necessary,  his  views  have  not  received  general  ac- 
ceptance ;  and  whatever  he  may  have  shown  as  to  the 
dietetic  requirements  under  the  conditions  presented  by 
the  subjects  of  his  experiments,  we  have  in  the  foregoing 
analysis  a  clear  indication  that  in  typhoid  fever  a 
daily  supply  of  a  hundred  grams  or  more  of  proteid  food 
gives  results  superior  to  those  of  a  more  limited  ration. 

In  Table  I  the  figures  in  the  column  for  nitrogen 
loss  are  no  mere  theoretical  abstractions,  but  represent 
very  obvious  and  very  important  clinical  conditions, 
that  is,  the  continuous  loss  of  body-weight.  The  min- 
imum nitrogen  deficit,  3.7  grams,  represents  the 
destruction  of  23.1  grams  of  body  protein,  or  with  the 


36  DIET   IN   TYPHOID   FEVER. 

associated  water  a  daily  loss  of  body-weight  of  about 
115  grams.  The  difference  between  this  smallest 
nitrogen  deficit  and  that  in  the  next  preceding  group, 
4.4  grams  daily,  would  mean  a  daily  saving  in  body- 
weight  of  135  grams  (4|^  ounces).  This  is  not  much 
for  a  single  day ;  but  continued  through  the  course  of 
the  disease  it  accumulates  to  a  considerable  aggregate ; 
and  this  loss  does  not  include,  be  it  noted,  the  loss  of 
the  comparatively  unimportant  body  fat,  but  embraces 
solely  the  destruction  of  the  far  more  valuable  body 
protoplasm.  Furthermore,  the  extra  weight  lost  as 
the  result  of  the  difference  between  the  most  efficient 
ration  and  a  less  efficient  ration  is  entirely  a  starvation 
result  and  not  at  all  due  to  the  conditions  of  the  disease 
itself. 

On  these  grounds  and  so  far  as  the  available  data 
indicate,  the  ration  of  protein  food  which  would  seem 
to  give  the  best  results  in  typhoid  feeding  during  the 
febrile  period  may  be  placed  at  about  100  to  110 
gram  [S^  oz.)  per  day  for  an  average-sized  person ;  cer- 
tainly at  more  rather  than  less  than  100  grams. 

During  the  first  few  days  of  apyrexia  nitrogen  met- 
abolism and  nitrogen  waste  are  much  the  same  as 
during  the  period  of  fever;  after  a  few  days,  however, 
the  capacity  of  the  body  for  nitrogenous  assimilation 
and  regeneration  is  restored  and  nitrogen  is  rapidly 
and  greedily  absorbed  by  the  system.  During  this 
period  the  nitrogen  ration  may  be  advantageously 
amplified. 


DIET   IN   TYPHOID   FEVER.  37 

Facts  and  Carbohydrates. —  As  is  the  case  with  pro- 
teid,  there  is  an  excessive  destruction  of  the  fatty 
body  tissues  in  typhoid  fever  above  the  power  of  the 
food  to  replace.  Exact  studies  of  carbon  metabohsm 
in  this  disease  have  not  yet  been  found  practicable 
and  have  not  yet  been  made,  so  that  we  have  not  the 
same  data  for  determining  the  ration  of  fats  and  car- 
bohydrates that  will  reduce  the  body  waste  to  a  mini- 
mum as  we  have  with  protein.  We  can  deal  with  this 
question  only  in  a  tentative  way. 

The  100  grams  of  proteid  required  in  the  daily  diet 
will  yield  about  400  calories,  which,  deducted  from  the 
total  energy  required  from  the  food,  1800  calories, 
leaves  1400  calories  to  be  supplied  by  the  fats  and 
carbohydrates.  This  energy  we  can  divide  between 
these  two  food  elements  in  any  convenient  or  practi- 
cable proportions.  We  might,  for  instance,  give  as 
much  fat  (which  has  the  highest  energy  value)  as  can 
be  tolerated  and  well  digested,  and  then  make  up  the 
remainder  of  the  quota  of  energy  with  carbohydrate. 
Thus,  if  we  give  60  grams  of  fat  daily  (energy  value, 
465  calories)  it  would  require  230  grams  of  carbohy- 
drate to  make  up  the  1400  calories  required ;  or  76 
grams  of  fat  and  200  grams  of  carbohydrate  would 
yield  1400  calories;  and  so  with  other  combinations. 

The  salts  required  in  typhoid  diet  present  no  special 
problem. 

Water. —  There  is  now,  as  there  has  nearly  always 
been  among  medical  authorities,  general  agreement  as 


38  DIET   IN   TYPHOID   FEVER. 

to  the  advisability  in  typhoid  fever  of  giving  water  in 
liberal  amount.  It  is  always  and  constantly  an  essen- 
tial element  of  food.  There  is  a  large  loss  of  water 
from  the  tissues  in  typhoid  that  needs  to  be  replaced. 
Investigations  have  shown  that  the  drinking  of  large 
amounts  of  water  promotes  the  digestion  and  absorp- 
tion of  foodstuffs,  especially  during  the  febrile  period 
of  typhoid.  Ingested  cold,  it  is  by  some  considered 
antipyretic.  It  flushes  out  the  bowel,  keeps  the  feces 
soft,  washes  out  the  products  of  intestinal  putrefaction, 
dilutes  the  toxic  blood,  promotes  the  elimination  and 
excretion  of  toxins  by  the  kidneys  and  skin. 

About  2  to  3  liters  (or  quarts)  of  water  is  generally 
deemed  the  proper  amount  to  include  in  the  typhoid 
diet  daily. 

To  summarize,  the  approximate  daily  nutritive  re- 
quirements of  a  proper  typhoid-fever  diet  for  a  person 
of  average  size,  so  far  as  can  be  estimated  from  the 
data  available,  appear  to  be  1800  calories  of  energy, 
100  grams  or  more  of  protein,  fat  and  carbohydrate 
enough  to  yield  about  1400  calories,  and  2  or  3  liters 
of  water,  during  the  pyrexia ;  more  in  convalescence. 

DIGESTION    AND    DIGESTIBILITY    IN    TYPHOID    FEVER. 

Having  attempted  to  establish  a  nutritive  standard, 
the  important  qualifying  question  next  arises  as  to  the 
ability  of  the  typhoid  patient  to  digest,  absorb,  and 
assimilate  the  food  that  theoretically  seems  to  be 
needed. 


DIET   m   TYPHOID   FEVER.  39 

It  is  generally  asserted  and  believed  that  the  digest- 
ive powers  in  typhoid  and  other  fevers  are  very 
greatly  impaired  and  even  altogether  abolished.  In 
snch  a  profound  disturbance  of  the  body  functions  as 
occurs  in  a  severe  disease  like  typhoid  fever  it  seems 
on  superficial  view  natural  and  almost  obvious  that 
digestion  must  be  enormously  lowered,  and  this  view, 
accordingly,  has  prevailed  almost  unchallenged  for 
ages,  though  it  has  been  based  more  on  general  im- 
pressions and  a  priori  deductions  than  on  exact  obser- 
vations. 

The  dry  tongue  and  mouth  often  seen  in  typhoid 
fever  naturally  suggests  deficiency  of  the  salivary 
secretion  and  salivary  digestion. 

Beaumont  in  the  classical  observations  on  digestion 
(1833)  claimed  that  in  the  "febrile  diathesis"  very 
little  or  no  gastric  juice  is  secreted  and  digestion  is 
much  impaired ;  it  is  obvious  from  his  statements,  how- 
ever, that  his  conception  of  fever  was  very  vague,  and 
that  his  subject  at  no  time  during  the  experiments 
suffered  from  real  fever,  but  only  from  transient  at- 
tacks of  acute  indigestion.  A  number  of  modern 
observers  agree  fairly  well  that  in  typhoid  and  other 
acute  fevers  there  is  usually  a  diminution  or  suppres- 
sion of  hydrochloric  acid  in  the  gastric  juice,  while 
the  pepsin  is  but  little  lowered  (Pavy,  Manassein,  Von 
den  Velden,  Hoppe-Seyler,  Edinger,  Glucinski,  Von 
Noorden,  Von  Leyden  and  Klemperer).  Sticker  and 
Zweifel  found  gastric  absorption  materially  retarded 


40  MET   IN   TYPHOID   FEVER. 

in  typhoid  fever.  The  motor  functions  of  the  stomach 
were  found  Uttle  impaired  by  Yon  Noorden. 

Few  rehable  observations  as  to  intestinal  digestion 
in  typhoid  fever  has  been  made.  The  presence  of  the 
lesions  and  the  occurrence  of  diarrhea  would,  however, 
be  expected  to  impair  the  digestive  activities  of  the 
bowel. 

These  observations  indicate  some  lowering  of  the 
digestive  secretions  and  powers.  This,  however,  does 
not  tell  the  whole  story  of  digestive  activity,  since  it 
is  a  matter  of  common  observation  that  patients  with 
decided  diminution  in  the  secretion  of  the  elements  of 
the  gastric  juice  may  nevertheless  be  capable  of  digestion 
sufficient  to  maintain  a  good  degree  of  body  nutrition. 

Fortunately  we  have  at  our  command  accurate,  re- 
liable, and  comparatively  simple  methods  by  which 
the  amount  of  food  material  digested  and  absorbed  can 
be  determined  with  great  precision.  This  consists  in 
making  exact  determinations  of  the  amount  of  food 
material  —  protein,  fat,  or  carbohydrate  —  ingested 
during  a  definite  period,  and  also  determining  the 
amounts  of  these  materials  as  discharged  in  the  feces 
for  the  corresponding  period.  The  difference  between 
the  material  ingested  and  that  dejected  necessarily 
represents  the  amount  digested  and  absorbed.  By  the 
use  of  this  method  we  are  able  to  determine  the  exact 
degree  of  digestion  in  cases  of  typhoid  fever,  and  esti- 
mate with  precision  the  average  falling  off  that  may 
be  expected. 


DIET   IN   TYPHOID   FEVER.  41 

Digestion  of  protein. —  The  diiference  between  the 
amount  of  nitrogen  introduced  in  the  food  and  that  ex- 
creted in  the  feces  indicates  the  amount  of  nitrogen 
that  has  been  digested  and  absorbed.  The  percentage 
of  nitrogen  absorbed  is  always  really  somewhat  more 
than  this  difference  indicates,  as  a  part  of  the  fecal 
nitrogen  is  derived  from  the  residue  of  bile  and  other 
intestinal  secretions,  cellular  debris  from  the  intestinal' 
mucosa,  etc.;  but  as  this  part  is  indeterminate  it  has  to 
be  disregarded,  and  digestion  is  always  somewhat  more 
complete  than  the  figures  indicate. 

The  observations  summarized  in  Table  I  comprise  a 
large  body  of  data  affording  a  substantial  basis  from 
which  we  can  form  a  definite  conception  of  the  power 
of  digesting  proteid  food  possessed  by  typhoid-fever 
patients.  In  many  of  the  individual  cases  the 
digestion  of  protein  is  very  low ;  but  in  the  general 
average  the  impairment  is  far  less  than  is  generally 
supposed. 

Referring  to  Table  I,  the  figures  in  the  eighth 
column  show  the  average  percentage  of  food  nitrogen 
digested  and  absorbed  in  the  typhoid  cases  there  sum- 
marized. It  will  be  seen  that  the  amount  of  the  daily 
nitrogen  ration  seems  to  have  a  distinct  effect  on  the 
proportion  of  food  nitrog.en  absorbed,  the  I'atio  of  the 
latter  increasing  from  57.9  per  cent  with  a  ration  of 
under  4  grams  to  88.1  per  cent  with  a  ration  of  16  to 
20  grams  and  also  24  to  28  grams  of  nitrogen,  and 
then  again  decreasing.     These  figures,  for  the  reasons 


42  DIET   IN    TYPHOID    FEVER. 

stated,  are  below  the  real  values,  and  the  disparity  or 
error  is  greater  with  the  smaller  rations  ;  yet  they  seem 
to  show  clearly  that  the  highest  digestive  efficiency 
for  proteids  in  typhoid  is  found  when  the  daily  nitro- 
gen ration  is  from  16  to  20  grams  and  over,  the  same 
ration  that  gives  the  smallest  nitrogenous  deficit. 
This  is  perhaps  because  the  digestive  powers  are  keyed 
up  to  their  maximum  efficiency  when  the  general 
body  nutrition  is  at  its  best,  and  is  another  reason  for 
regarding  the  nitrogen  ration  of  16  to  20  grams  or 
over  as  the  best  one  for  typhoid. 

The  general  average  digestion  and  absorption  of 
nitrogen,  or  protein  food,  in  the  entire  series  was  80.9 
per  cent  during  the  febrile  period  (88.1  per  cent  with 
the  optimum  diet),  88.5  per  cent  during  convalescence. 
These  figures,  compared  with  the  coefficients  of  diges- 
tibility of  protein  in  health,  namely,  97  per  cent  for 
animal  protein,  84  per  cent  for  vegetable  protein,  and 
92  per  cent  for  protein  of  mixed  diet  (Atwater),  indi- 
cate a  general  average  falling  off  in  the  digestibility 
of  nitrogenous  food  of  about  9  per  cent  (4  per  cent 
with  the  optimum  diet)  during  the  pyrexia  and  5  per 
cent  during  the  convalescence  of  typhoid  fever. 

In  order  to  obtain  a  measure  of  digestibility  of  dif- 
ferent kinds  of  proteid  food  during  the  pyrexia  in 
typhoid  fever,  I  have  reclassified  the  metabolism  ob- 
servations summarized  in  Table  I  according  to  the 
kind  of  food  given.  The  results  are  presented  in 
Table  II. 


DIET   IN   TYPHOID   FEVER. 


43 


The  next  to  the  last  column  of  this  table  shows  the 
percentage  of  food  nitrogen  or  protein  ingested  that  is 
digested  and  absorbed,  and  ranges  from  93.9  per  cent 
for  white  of  egg  to  70.2  per  cent  for  milk  and  soup. 
Compared  with  the  general  standard  of  digestion  and 
absorption  in  health,  the  various  foods  mostly  show"  a 
falling  off  of  five  to  ten  per  cent. 


TABLE  II.     Average   daily  Digestion   of   Protein  of  Various 
Kinds  of  Food  during  the  Febrile  Period  of  Typhoid  Fever. 


Food  (Mainly). 


Eggs  -  yolks 

Eggs  -  whites 

Meat  juice 

Ham 

Milk  under  8  grams  nitro- 
gen daily 

Milk  over  8  grams  nitro- 
gen daily 

Milk  and  soup 

Milk,  soup,  and  tata 
albumen 

Milk  and  bread 

Milk,  bread,  and  alcohol- 
ics  

Milk  and  oatmeal 

Milk,  cream,  and  lactose. 

Milk  and  meat  powder. . 

Milk,  bread,  and  meat. . . 

Milk,  bread,  eggs,  meat, 
etc 

Milk,  cream,  eggs,  bouil- 
lon, etc 

Milk,  eggs,  soup,  etc. . . . 

Rice 

Porridge  (of  fine  grits) . . 


General  average. 


In  Typhoid  Fever  (Pyrexia). 


159 


.2  9 


Days 


Grams.  Grams. 


0 

•2 
4 
5 

12 

20 
32 

20 
164 

163 

4 

4 

9 

83 

95 

17 

67 

2 

8 


716 


QJOS   r-i 


,a'6. 


12.4 
19.8 
14.6 
IS. 4 

6.0 

12.2 
6.7 

10.1 
14.1 

6.4 

7.2 

10.4 

17.2 

13.2 

23.5 

13.9 

14.6 

2.5 

17.4 


11.7 


Grams. 


1.0 

1.2 

.9 

1.6 


1.1 

2.0 

2.1 

2.6 

1.5 
1.2 
1.2 
1.7 
2.1 

4.5 

1.0 

2.0 

.5 

1.9 


1.9 


11.4 
18.6 
13.7 
16.8 


11.1 

4.7 

8.0 
11.5 

4.9 

6.0 

9.2 

15.5 

11.1 

19.0 

12.9 

12.6 

2.0 

15.5 


9.8 


Per 

cent. 


91.9 
93  9 
93.8 
91.3 

86.7 

91.0 
70.2 

79,2 
81.6 

76.6 
83.3 
88.5 
90.1 
84.1 

80.9 

92.8 
86.3 
80.0 
89.1 


Per 
cent. 


83.6 


97 
97 
97 
97 


97 


92 


92 
97 
97 
92 


97 

85 
85 


92 


44 


DIET   IN    TYPHOID   FEVER. 


Digestion  of  fat. —  Studies  of  digestion  and  absorp- 
tion of  fat  during  typhoid  fever  have  been  made, 
secundem  artem,  by  Hoesshn,  Tschernoff  and  Laden- 
burger  in  17  cases  of  the  disease.  A  summary  of  their 
results  is  given  in  the  accompanying  Table  III. 

TABLE  III.    Digestion  and  Absorption  of  Fat  in  Typhoid  Fever 


Food. 

Percentage  of  food 
fat   digested  and 
absorbed. 

Number 
of 

Cases. 

Number 

of 

Experiments. 

Milk: 

Pyrexia 

90.6 
85.6 
91.6 
94.3 
72.9 
91.9 

10 

4 
5 
2 
.3 

2 

12 

Convalescence 

Milk,  eggs,  soup,  etc 

"Rp-cpc  — .  volks      

4 
5 

2 

Ham 

Porridge 

3 

2 

General  average  

88.5 

17 

28 

Note.    Four  experiments  with  milk  and  one  with  ham  were  made  during  apyrexia, 
the  others  during  pyrexia.    Total  duration  of  experiments  109  days. 


Comparing  these  results  with  the  average  digesti- 
bility of  fat  in  health,  namely,  96  per  cent  for  fat  in 
animal  food,  90  per  cent  for  fat  in  vegetable  food  and 
95  per  cent  for  fat  of  mixed  diet  (Atwater),  it  appears 
that  in  tj^phoid  fever  the  digestion  of  fat  falls  off,  with 
ordinary  diet,  about  1  to  10  per  cent,  or  in  the  gen- 
eral average  6.5  per  cent. 

Digestion  of  carhohydrcde. —  Aside  from  a  single  ob- 
servation by  Ladenburger  I  have  found  recorded  no 
investigations  of  the  digestion  of  carbohydrates  in  ty- 
phoid fever.     As  carbohydrates  are  in  health  ordinarily 


DIET   IN   TYPHOID    FEVER. 


45 


more  easily  and  completely  digested  and  absorbed  than 
is  protein  or  fat,  it  is  probable  that  any  diminution  in 
their  absorption  in  typhoid  fever  would  be  less,  or  cer- 
tainly no  greater,  than  that  for  protein  or  fat. 

Total  solids. —  Some  experiments  on  the  digestion 
and  absorption  of  the  total  solids  of  the  food  (dry  solids 
of  food  minus  dry  solids  of  feces)  made  by  Hoesslin  in 
8  cases  of  typhoid  fever  (18  experiments,  all  but  one 
being  during  pyrexia)  are  summarized  in  Table  IV  for 
comparison  with  the  corresponding  data  for  health : 

TABLE  IV.     Digestion  and  Absorption  of  Total  Solids 
IN  Typhoid  Fevek. 


Per  cent  of  solids  of  food  digested 
and  absorbed. 

Food. 

In 

Typhoid  Fever 

(Hoesslin). 

In 

Health 
(Rubner). 

Milk 

93.2 
91.2 
91.2 
92.4 
88.8 

86.. 3 
91.0 

90.6 

90  9 

Milk,  eggs,  soup,  etc 

Eggs  —  whites 

Effg's  —  volks 

94.7 

Ham 

Roast  meat 

94.9 

Meat  juice  and  soup 

Porridge 

Macaroni 

94.3 

Rice 

95  1 

General  average 

90.8 

94.0 

In  general,  then,  it  appears  from  precise  determina- 
tions that  the  average  falling  off  of  digestive  and  ab- 
sorptive power  for  all  sorts  of  food  material  during  the 
febrile  period  of  typhoid  fever  does  not  exceed  5  or  10 


46  DIET   IN   TYPHOID   FEVER. 

per  cent.  This  decrease  is  far  less  than  is  generally 
believed  to  be  the  case.  The  difference  between  di- 
gestion in  health  and  typhoid  fever  is  less  than  the 
difference  in  health  between  various  articles  of  food 
ordinarily  regarded  as  digestible  ;  for  instance,  the  dif- 
ference between  the  digestibility  in  health  of  the  pro- 
tein of  eggs  and  of  bread,  both  digestible  foods,  is 
about  13  percent.  The  high  average  digestibility  of 
88.1  per  cent  with  a  diet  containing  100  grams  or 
more  of  protein  daily,  shows  that  typhoid  patients  can 
easily  utilize  that  amount  of  protein.  It  may  be  con- 
cluded, therefore,  that  the  digestive  powers  in  typhoid 
fever  ordinarily  are  or  may  be  so  little  lowered  as  to 
be  entirely  adequate  to  meet  all  proper  demands  that 
may  be  made  upon  them. 

It  is  to  be  expected  that  in  different  cases  of  the  dis- 
ease will  be  manifested  different  degrees  of  impair- 
ment of  digestion,  and  that  in  the  bad  cases  the  falling 
off  of  digestive  power  may  be  much  greater  than  I 
have  indicated.  The  observations  that  I  have  collected 
show,  however,  how  great  digestive  ability  can  be  ex- 
pected in  some  cases,  average  and  typical  cases  of 
typhoid  fever.  Some  patients  obviously  digest  well ; 
and  because  in  bad  cases  the  patients  are  unable  to  di- 
gest a  certain  food  is  no  reason  for  withholding  it  from 
a  patient  who  can  readily  digest  it. 

What  may  be  called  subjective  digestibility  —  the 
subjective  sensations  and  phenomena  accompanying 
digestion,  personal  likes  and  dislikes,  the  ease  or  the  dis- 


DIET   IN    TYPHOID   FEVER.  47 

comfort  with  which  diff erant  kinds  of  food  are  digested 
by  different  persons  —  is  not  amenable  to  scientific 
analysis,  but  is  a  matter  of  personal  peculiarity  and 
idiosyncrasy  that  can  be  determined  only  by  experi- 
ence or  trial  in  each  individual  case.  Considerations 
of  this  character  apply  as  much  to  milk  and  soup  as  to 
any  other  diet. 

While  we  can  often  count  on  much  better  digestive 
power  than  has  been  generally  supposed,  it  is  ob- 
vious that  the  typhoid  dietary  should  include  only  the 
most  digestible,  plain,  and  substantial  articles  of  food, 
excluding  those  that  are  notoriously  indigestible. 
Theoretically,  foods  should  be  chosen  that  will  be  di- 
gested and  absorbed  in  the  stomach  and  upper  part  of 
the  small  intestine,  where  the  involvement  of  the  ali- 
mentary structures  is  least ;  but  practically  such  a  dis- 
tinction would  be  difficult  and  unnecessary  to  make. 

When  necessary  the  usual  measures  can  be  employed 
to  stimulate  digestion. 

PALATABILITT. 

A  requirement  in  typhoid  diet  which  should  be  more 
generally  recognized  is  that  it  be  made  as  palatable, 
appetizing,  and  agreeable  to  the  patient  as  possible. 
This  will  conduce  greatly  to  the  patient's  comfort ;  it 
may  induce  him  to  take  a  needed  larger  amount  of 
nourishment ,  it  should,  according  to  Pawlow's  teach- 
ings, materially  increase  his  digestive  powers.     Food 


48  DIET  IN   TYPHOID   FEVER. 

that  is  not  relished  or  is  actually  disliked  is  apt  to  be 
poorly  digested  and  badly  borne.  Variety  in  the  diet 
will  similarly  conduce  to  efficiency,  as  monotonous 
continuance  in  any  unaccustomed  or  limited  diet  ex- 
cites discomfort,  repugnance,  revolt,  and  active  indi- 
gestion. 

IlSrNOCUOUSNESS. 

The  diet  in  typhoid  fever  should  not  cause  harm 
under  the  special  conditions  present  in  this  disease. 
Numerous  bad  effects  are  charged,  with  more  or  less 
justice,  to  dietetic  improprieties. 

Gastric  indigestion. —  Gastric  irritability,  vomiting, 
nausea,  and  intolerance  of  food  sometimes  occurring  in 
typhoid  fever  are  usually  due  more  to  the  conditions 
of  the  disease  than  to  improper  food.  If  the  food 
should  cause  or  contribute  to  the  gastric  trouble  it 
should  be  changed  accordingly,  but  the  kinds  of  food 
that  will  be  best  borne  must  be  determined  for  each 
case  individually. 

hitestinal  indigestion. —  The  food  should  so  far  as 
possible  be  such  as  not  to  conduce  to  undue  bacterial 
growth  in  the  intestine,  resulting  in  fermentation,  gas 
formation,  aud  the  production  of  flatulence  and  tympa- 
nites, or  in  abnormal  putrefactive  processes  with  the 
generation  and  absorption  of  troublesome  toxins.  It 
should  not  irritate  the  bowels  or  tend  to  cause  or  in- 
crease   diarrhea.     These   troubles  are  usually  due  to 


DIET   m   TYPHOID   FEVER.  49 

the  lesions  and  conditions  of  the  disease  quite  irrespec- 
tive of  food ;  but  the  diet  selected  should  obviously  be 
such  as  will  be  the  best  borne,  and  to  the  extent  to 
which  the  intestinal  indigestion  and  irritation  may  be 
caused  by  the  food  should  the  diet  be  corrected  and 
rearranged.  The  cases  must  be  individualized,  and 
the  causes  and  remedies  for  the  troubles  specially  de- 
termined for  each.  With  a  large  diet  list  to  choose 
from  there  is  a  better  chance  in  both  gastric  and  in- 
testinal indigestion  of  beiug  able  to  find  articles  of 
food  than  can  be  well  borne. 

Effect  on  ulcers. —  It  is  held  of  the  utmost  impor- 
tance that  the  food  in  typhoid  fever  should  be  such  as 
to  cause  the  least  possible  disturbance  or  harm  to  the 
ulcerated  patches  in  the  bowel.  The  primary  and 
chief  cause  of  the  ulcerative  process  is  the  action  of 
the  bacilli  in  the  tissues  ;  but  it  is  possible  or  conceiv- 
able that  the  solution  of  continuity  and  the  resulting 
danger  of  hemorrhage  or  perforation  could  be  second- 
arily increased  through  the  action  of  improper  food, 
(a)  Great  distension  of  the  bowel  by  gas,  causing  ten- 
sion on  a  thinned,  ulcerated  area  might  produce  fur- 
ther rupture  or  perforation.  This  is  a  question  of  in- 
testinal indigestion,  to  be  corrected  by  careful  selec- 
tion of  the  food,  emptying  of  the  bowel,  intestinal  anti- 
septics, or  other  treatment,  (b)  Continuous  peristal- 
tic motion  of  the  ulcerated  area  is  not  a  condition  most 
conducive  to  heahng.  It  is  however,  impossible  to  se- 
cure absolute  rest  for  the  healing  of  typhoid  ulcers. 


50  DIET"  IN   TYPHOID   FEVER. 

There  is  necessarily  some  peristalsis,  and  the  amount 
of  motion  induced  by  ordinary  and  proper  food  is 
probably  much  less  than  is  caused  by  the  use  of  those 
purgatives  which  there  is  no  hesitation  in  using  in  the 
cases  presenting  constipation.  The  conceivable  dan- 
ger from  normal  peristalsis  may  therefore  be  disre- 
garded, beyond  the  obvious  necessity  of  arranging  the 
diet  so  as  to  minimize  diarrheal  tendencies,  (c)  Just 
as  poor  nutrition  retards  the  healing  of  superficial  ul- 
cers, so  insufficient  feeding  may  be  supposed  to  retard 
the  healing  of  typhoid  ulcers  ;  and  the  same  reason 
would  seem  to  exist  for  liberal  feeding  to  promote  the 
healing  of  the  latter  as  prompts  the  surgeon  to  feed 
liberally  to  hasten  healing  of  surface  ulcers,  (d)  The 
pressure  of  solid  or  bulky  masses  of  food  residue  upon 
the  ulcers  may  conceivably  cause  them  to  rupture  or 
irritate  them  to  additional  inflammation.  This  possi- 
bility introduces  the  very  important  requirement  that 
the  food  in  typhoid  fever  should  be  such,  and  so  pre- 
pared, that  the  residue  in  the  intestine  shall  be  fluid, 
or  in  a  state  of  fine  division,  non-irritating,  of  mini- 
mum bulk,  and  kept  well  softened  or  in  a  semifluid  or 
pasty  condition  by  water. 

As  may  easily  be  seen  at  autopsies,  all  ordinary  food 
material,  liquid  or  solid,  during  its  passage  through 
the  small  intestine  is  normally  in  a  pasty  condition, 
with  the  solid  elements  reduced  to  a  state  of  very  fine 
division,  bland  and  mechanically  unirritating.  Three 
kinds  of  solid  food  masses  of  size  sufficient  to  be  me- 


DIET   m   TYPHOID   FEVER.  61 

chanically  injurious  may  be  present  in  the  small  bowel : 
(a)  Solid  food  that  is  not  sufficiently  masticated  or  other- 
wise comminuted  j  (b)  indigestible  portions  of  food, 
chiefly  undivided  fragments  of  vegetable  tissue  con- 
taining much  cellulose,  as  skins  of  fruits,  grains,  etc. ; 
and  (c)  lumps  of  curdled  milk.  In  the  large  intestine, 
in  addition,  solid  fecal  masses  may  be  produced  by  in- 
spissation  of  the  intestinal  contents  into  scybala. 

These  considerations  teach  that  in  typhoid  fever  the 
food  should  be  liquid,  or  soft  and  easily  divisible ;  or  if 
solid  (supposing  solid  food  to  be  permissible),  it  should 
be  given  in  a  finely  divided  condition,  with  all  large 
undivided  masses,  as  of  cellulose,  excluded.  The  food 
should  in  general  be  such  as  yields  a  small  fecal  resi- 
due. Plenty  of  water  should  be  given,  that  the  intes- 
tinal contents  may  be  kept  properly  moistened.  The 
bowels  should  be  kept  open  (if  constipated),  to  prevent 
accumulation,  inspissation,  and  hardening  of  the  feces. 
With  these  precautions,  the  food  material  as  it  passes 
through  the  bowel  ought  to  be,  as  nearly  as  can  be 
made,  of  the  bland,  finely-divided,  semifluid,  and  non- 
irritating  character  indicated  in  this  disease. 

This  leads  to  the  question  as  to  the  necessity  that 
the  food  in  typhoid  fever  be  fluid.  From  time  imme- 
morial solid  food  has  been  regarded  as  totally  inadmissi- 
ble in  fever.  In  the  literature,  however,  this  doctrine 
is  laid  down  dogmatically  and  without  proof,  as  if  it 
were  self-evident  and  did  not  require  critical  consider- 
ation and  demonstration.     A  great  deal  is  taken  for 


52  DIET   IN   TYPHOID   FEVER. 

granted  in  this  assumption,  and  if  it  is  true  it  is  cer- 
tainly worthy  of  being  estabhshed  on  scientific  dietetic 
principles  rather  than  on  dogmatic  assertion  or  vague 
impressions.  It  is,  nevertheless,  all  but  universally 
held  that  in  this  disease  exclusive  liquid  diet  is  abso- 
lutely essential,  that  milk  is  the  ideal  liquid  food,  and 
that  solid  and  even  soft  food  is  dangerous  and  contra- 
indicated.  In  spite  of  its  general  acceptance,  the  ad- 
vocates of  a  more  liberal  and  varied  diet  disagree  with 
this  view  in  every  particular. 

The  idea  seems  to  be  that  solid  food  is  less  digestible 
than  liquid  food,  more  irritating  to  the  intestines,  goes 
through  the  alimentary  canal  in  a  more  solid  and 
bulky  form,  or  in  some  occult  manner  augments  the 
disease  processes  in  a  way  that  a  corresponding  amount 
of  liquid  food  will  not.  None  of  these  suppositions  is 
necessarily  true.  Well-divided  solid  proteid  is  prac- 
tically as  easily  digestible  as  the  liquid  proteid  of  milk 
or  eggs.  The  liquid  forms  of  albumen  have  to  go 
through  the  same  process  of  digestion  as  the  solid 
forms  before  they  can  be  absorbed ;  raw  egg  albumen, 
for  instance,  even  if  diluted  and  thinned,  is  utterly 
incapable  of  direct  absorption  as  such,  and  it  is  doubt- 
ful if  raw  egg  is  much  more  easily  digestible  than  is 
cooked  egg.  The  digestive  juices  are  amply  sufficient 
to  convert  solid  proteid  and  carbohydrate  material  in- 
to liquid  form.  As  to  leaving  less  fecal  residue,  the 
solids  of  milk  in  health  yield  much  more  fecal  residue 
than  do  hard-boiled  eggs  or  meat;   according  to  some 


DIET   IN   TYPHOID   FEVEE.  53 

determinations  two  and  three  times  as  much ;  and  no 
soKd  food  can  cause  more  intestinal  indigestion  or  irri- 
tation than  milk  often  does. 

Liquid  foods  offer  certain  distinct  disadvantages. 
Owing  to  their  bulk  and  degree  of  dilution,  it  is  often 
impossible  to  introduce  an  adequate  amount  of  nutri- 
tive material  by  their  exclusive  use.  Their  diluted 
condition  may  actually  impair  their  digestibility,  by 
causing  too  great  dilution  of  the  gastric  juice;  just  as 
in  the  treatment  of  ordinary  dyspepsias  the  drinking 
of  to  much  liquid  at  meals  is  discouraged  on  that 
ground. 

What  is  to  be  regarded  as  liquid  and  what  as  solid 
food  ?  The  idea  that  solid  food  will  remain  solid,  and 
liquid  food  remain  liquid,  in  their  passage  through  the 
alimentary  canal  is  contradicted  by  common  experi- 
ence. Proper  and  properly  prepared  solid  food  enters 
the  bowel  in  pasty  or  practically  fluid  form.  For  the 
purposes  of  typhoid  diet,  which  has  the  better  claim  to 
being  termed  liquid  food,  previously  solid  food  that  be- 
comes fluid  in  the  stomach  and  intestine,  or  previously 
liquid  food,  like  milk,  that  becomes  solid  in  the  stom- 
ach ?  Of  all  foods,  certainly  of  all  foods  that  could 
reasonably  be  given  to  very  ill  patients,  milk  is  or  may 
be  the  most  solid;  since  no  other  food  is  capable  of 
passing  through  the  entire  intestinal  canal  and  being 
ejected  with  the  feces  in  such  large  or  hard  masses. 
The  previous  form  of  a  food  may  be  very  deceptive  as 
to  its  solid  content ;  milk,  for  example,  contains  more 


54  DIET   IN   TYPHOID   FEVER. 

solids  than  *do  turnips.  It  would  seem  rational  that 
the  previous  condition  of  fluidity  or  solidity  of  the  food 
is  quite  irrelevant ;  it  is  its  consistency  in  the  intestine 
that  is  of  importance  in  typhoid  feeding. 

Metaholic  excess. — It  is  conceivable  that  relative  over- 
feeding in  typhoid  fever  might  overload  or  clog  the 
circulation  with  superfluous  nutritive  materials,  or  an 
excess  of  katabolic  products,  to  the  detriment  of  the 
patient's  general  condition.  With  the  present  attitude 
of  the  profession  such  as  it  is,  overfeeding  is  little  likely 
to  occur,  and  the  error,  if  recognized,  could  be  easily 
corrected. 

Renal  effects. —  Obviously  the  kidneys  in  typhoid 
fever  should  not  be  overburdened  with  the  necessity  of 
excreting  an  excessive  amount  of  katabolic  material. 
Fortunately  the  kidneys  ordinarily  suffer  compara- 
tively little  impairment  and  nearly  always  retain  re- 
markably good  functional  power  in  this  disease,  and 
only  rarely  would  they  require  to  be  specially  con- 
sidered in  the  arrangement  of  the  diet. 

Effect  on  body  temj^erature. —  The  diet  in  typhoid 
fever  should  be  so  managed  as  to  minimize  any  ten- 
dency it  may  have  to  increase  fever  or  cause  the  re- 
currence of  pyrexia  in  the  postfebrile  stage.  It  is 
around  this  point  that  much  of  the  controversy  on  the 
diet  question  centers. 

If  the  body  temperature  depended  directly  on  the 
amount  of  heat  production  then  it  would  be  influenced 
by  the  amount  of  food  eaten  and  would  show  great 


DIET  IN   TYPHOID   FEVEE.  55 

fluctuations  according  to  the  diet.  From  a  superficial 
view,  a  large  amount  of  food  by  liberating  a  larger 
amount  of  energy  convertible  into  heat  might  be  ex- 
pected to  raise  the  body  temperature,  or  at  least  not 
to  lower  it;  and  in  starvation  conditions  there  is  a 
lowering  of  the  body  temperature.  Body  temperature 
is  not,  however,  a  resultant  of  body  oxidation  alone, 
but  of  the  balance  between  heat  production  and  heat 
dissipation.  Heat  production  may  vary  widely,  up 
and  down,  but  the  balance  and  the  body  temperature 
normally  remain  constant,  as  heat  dissipation  varies 
correspondingly.  It  is  a  disturbance  of  the  heat  regu- 
lating apparatus  that  results  in  the  retention  of  heat 
and  elevation  of  the  body  temperature  that  constitutes 
fever.  A  certain  amount  of  oxidation  is  necessary  to 
supply  the  energy  needed  for  the  performance  of  the 
body  activities  of  the  fevered  organism ;  and  any  lack 
in  the  energy  supplied  by  needed  food  will  be  compen- 
sated by  a  correspondingly  increased  combustion  of 
body  tissues  which  will  maintain  oxidation  and  the 
fever  at  the  same  level.  Nor  have  experiments 
(Hoesslin)  shoWn  any  material  difference  in  the  body 
temperature  under  a  spare  and  a  liberal  diet. 

The  amount  of  heat  required  to  raise  the  tempera- 
ture of  the  body  a  few  degrees  (58  calories  being  suffi- 
cient to  raise  a  body  weighing  70  kilograms  1°  C.)  is 
only  a  small  part  of  the  total  heat  production ;  thus,  so 
little  as  three  ounces  of  milk  would  yield  enough 
energy  (if  not  otherwise  expended)  to  raise  the  tern- 


56  DIET   IN   TYPHOID   FEVER. 

perature  of  an  average  sized  individual  two  degrees 
Farenheit  (90  c.  c.  of  milk  would  raise  it  1°  C).  Even 
on  the  lowest  diet  there  is  far  more  heat  produced 
than  is  sufficient  (if  retained)  to  cause  high  fever,  and 
the  temperature  changes  of  the  body  represent  but  a 
small  part  of  the  energy  metabolism  of  the  organism. 

That  the  condition  of  pyrexia  j;er  se  is  essentially 
a:ffected  by  the  kind  of  food,  or  within  ordinary  limits 
is  materially  aggravated  by  or  is  a  contraindication  to 
an  abundance  of  food,  properly  given,  is  not  therefore, 
shown.  The  effect  of  food  is  certainly  not  feared  in 
the  fever  of  such  conditions  as  tuberculosis.  The  tem- 
perature in  both  the  febrile  and  apyretic  periods  of 
typhoid  fever  is  subject  to  sudden  and  inexplicable 
fluctuations.  Such  sudden  changes  occurring  coinci- 
dently  with  some  slight  change  in  diet  are  apt  to  be 
wrongfully  charged  to  the  food.  These  fluctuations 
may  occur  under  any  diet,  and  are  usually  entirely  un- 
connected with  the  food. 

Relapses  are  often  charged  to  dietetic  improprieties. 
The  occurrence  of  relapses  after  a  change  in  diet  is 
more  apt  to  be  coincidental  than  causal.  Relapses  oc- 
cur under  a  milk  diet  or  any  diet,  and  when  no  change 
has  been  made  in  the  feeding.  That  true  relapses  can 
be  caused  by  food  is  being  doubted  more  and  more ; 
relapses  are  now  regarded  as  being  due  to  reinfections 
and  repetitions  of  the  disease  process,  and  it  is  difficult 
to  see  how  food  can  have  any  agency  in  causing  these, 
any  more  than  in  producing  the  original  attack. 


DIET  IN   TYPHOID   FEVER.  57 

Only  one  febrile  condition  is  clearly  chargeable  to 
food,  the  febris  carnis,  or  food  fever.  The  true  febris 
carnis  is  due  not  so  much  to  the  kind  of  food  as  to  an 
abrupt  change  or  increase  in  its  amount.  An  amount 
of  food  that  if  suddenly  given  will  cause  fever  can  be 
gradually  worked  up  to  without  any  symptoms.  The 
cause  of  febris  carnis  is  unsettled ;  some  regard  it  as 
of  nervous  origin,  similar  to  the  fever  that  may  be 
aroused  by  excitement,  etc.,  in  ill  persons  ;  or,  in  the 
unstable  condition  of  the  heat-regulating  apparatus 
after  typhoid,  this  apparatus  being  unable  to  accommo- 
date itself  quickly  to  abrupt  changes  in  diet,  the  sud- 
den liberation  of  a  large  amount  of  heat  energy  from 
the  unwonted  quantity  of  food  may  cause  a  rise  in 
body  temperature.  Some  regard  the  liability  to  food 
fever  as  largely  a  starvation  effect,  and  that  the  ten- 
dency to  it  is  increased  on  insufficient  nourishment. 
Even  when  it  occurs,  the  true  febris  carnis  is  gener- 
ally of  brief  duration  and  very  little  importance,  very 
different  from  a  genuine  relapse. 

The  advocates  of  liberal  diet  therefore  believe  that, 
while  no  exaggerated  fear  need  be  felt  of  the  effect  of 
food  on  the  fever,  changes  in  the  typhoid  dietary 
should  be  made  gradually,  watchfully,  and  cautiously, 
never  suddenly. 

Effect  on  coagulation  of  hlood. —  The  effect  of  food 
materials  on  the  coagulation  of  the  blood  has  an  occa- 
sional bearing  on  the  selection  of  the  diet  in  typhoid 
fever.     In  intestinal  hemorrhage  it  would  be  desirable 


08  DIET    IX    TYPHOID    FEVER. 

to  have  the  coagulability  of  the  blood  increased ;  in 
the  cases  of  thrombosis,  the  contrary  effect  vrould  be 
advantageous.  According  to  Wright,  the  coagulability 
of  the  blood  is  diminished  during  the  febrile  period  in 
typhoid  fever:  during  convalescence  it  is  increased, 
largely,  apparently,  as  the  result  of  liberal  ingestion 
of  milk.  Calcium  salts  being  essential  to  the  clotting 
of  blood,  the  administration  of  lime  salts  may  greatly 
accelerate  coagulation  :  as  milk  contains  these  salts  in 
abundance  it  has  been  found  capable  of  markedly 
shortening  coagulation  time.  Gelatin  is  also  supposed 
to  favor  coagulation.  When  it  is  desirable  to  increase 
coagulation,  therefore,  as  in  actual  or  threatened  hem- 
orrhage, milk  and  gelatin  would  be  of  ser\dce  ;  but 
when  thrombosis  threatens  or  occurs  they  would  be 
contraindicated.  or  if  used  should  be  so  prepared  as  to 
abolish  their  coagulating  properties  ('decalcification  of 
milk). 

THE    DIETAEY    IX    TYPHOID    FEVER. 

Having  considered  the  essential  requirements  of  ty- 
phoid diet  as  to  nutritiveness.  digestibility,  palatability, 
and  innocuousness,  it  is  next  in  order  to  consider  the 
acceptability  in  these  respects  of  the  various  articles 
of  food  available  for  use.  The  discussion  of  this  part 
of  the  subject  rests  largely  on  the  composition  and  di- 
gestibility, the  proportion  of  solids  absorbed  and  the 
proportion  of  fecal  residue,  etc.,  of  the  various  foods, 
according  to   the    standard    determinations    of    Voit, 


DIET    IX   TYPHOID   FEVER.  59 

Rubner,    At  water,     and   others ;     also     on    the    data 
brought  out  in  Tables  11,  III,  and  IV. 

Milk. —  To  yield  the  amount  of  protein  and  energy 
which  I  have  presented  reasons  for  regarding  as  stand- 
ard, about  3  liters  (or  quarts)  of  milk  would  have  to 
be  given  daily,  representing  about  100  grams  of  pro- 
tein and  2,000  calories.  If  this  amount  could  be  given 
continuously  to  all  typhoid  patients  without  ill  effects, 
the  question  of  typhoid  diet  would  be  a  simple  one; 
but  it  is  not  often  practicable  to  give  this  amount. 
Under  the  present  system  typhoid  patients  generally 
receive  1,500  to  2,000  c.  c.  (3  to  -l  pints)  of  milk  a  day 
or  its  equivalent,  a  quantity  entirely  insufficient  for 
proper  nutrition,  not  much  more  than  half  the  amount 
needed.  The  present  general  dietetic  method  in  ty- 
phoid fever  must  be  characterized  as  one  of  partial 
starvation,  by  which,  thoughtlessly  and  unknowingly 
perhaps,  but  usually  unnecessarily,  conditions  of  star- 
vation are  added  to  the  conditions  of  the  disease.  The 
fact  that  patients  are  deliberately  compelled  to  suffer 
for  weeks  the  distressing  pangs  of  hunger,  which 
might  be  taken  as  a  call  of  nature  for  more  food,  with- 
out any  attempt  at  relief,  is  another  reason  for  sus- 
pecting that  typhoid  patients  are  underfed. 

The  constituents  of  milk  show  a  very  satisfactory 
average  digestibility  in  typhoid  fever,  though  not  man- 
ifesting any  superiority  in  this  respect  over  eggs  or 
meat.  The  fecal  residue  left  from  milk  (in  health,  at 
least)  is  greater  than  that  from  eggs,  beef,  fish,  or 
white  wheat  bread. 


60  DIET  IN   TYPHOID   FEVER. 

Some  patients  dislike  milk,  and  it  is  apt  to  become 
especially  obnoxious  when  continuously  given  in 
large  amounts.  Milk  is  capable  of  causing  the  sever- 
est kind  of  intestinal  indigestion,  as  often  in  infants, 
with  fermentation,  gas  formation,  production  of  irri- 
tant toxins,  diarrhea,  etc. ;  none  of  the  ordinary  ani- 
mal foods  is  worse,  if  as  bad,  in  this  respect.  The  bac- 
terial contamination  of  ordinary  commercial  milk  may 
(as  shown  by  Edsall)  cause  fermentative  and  putrefac- 
tive disturbances  in  the  weakened  condition  of  typhoid 
patients,  when  in  healthy  adults  there  is  sufficient  re- 
sisting power  to  overcome  this  tendency. 

That  milk  is  self-evidently  the  best  food  for  adults 
is  open  to  question.  If  it  were  necessary  to  limit  the 
diet  to  a  single  article  of  food,  milk  would  unquestion- 
ably be  the  best,  and  it  is  one  of  the  most  important 
ingredients  in  any  diet.  It  presents,  however,  certain 
disadvantages,  as  coagulability,  fermentability,  bulk, 
etc.,  and  while  it  is  a  natural  and  complete  food  for 
infants  it  is  not  adapted  to  exclusive  nourishment  of 
adults  except  in  amounts  that  are  practically  prohibi- 
tive. A  great  trouble  with  its  digestion  consists  in  its 
coagulation  in  the  stomach,  an  unfortunate  condition 
that  occurs  with  no  other  food.  No  other  food  that 
could  reasonably  be  given  is  capable  of  passing  through 
the  intestine  in  such  large  and  solid  masses  as  the 
milk  curds  that  are  frequently  passed  with  the  stools 
in  typhoid  fever.  It  does  not  necessarily  follow  that 
because  milk  is  fluid  it  is  on  that  account  more  easily 


DIET   IN   TYPHOID   FEVER.  61 

digestible,  less  irritating  to  the  bowels,  or  leaves  less 
fecal  residue. 

In  view  of  these  manifest  disadvantages,  it  is  diffi- 
cult to  see  how  the  general  esteem  in  which  milk  is 
held  as  the  safest,  most  efficient,  and  best  food  for  this 
disease  is  justified.  The  objections  that  are  urged 
against  solid  food  apply  with  equal  and  even  greater 
force  against  milk.  When  milk  is  badly  borne,  as 
frequently  occurs  in  typhoid,  it  is  one  of  the  worst  of 
foods,  and  under  these  circumstances  it  produces  just 
the  conditions  that  make  it  especially  objectionable 
and  dangerous  in  typhoid  fever.  The  appearance  of 
curds  in  the  stools  should  constitute  an  unvariable 
indication  for  immediate  reduction  or  entire  with- 
drawal of  milk  from  the  diet.  In  acute  intestinal  dis- 
orders in  infants  milk  is  regarded  as  highly  harmful; 
there  is  no  reason  why  it  is  not  equally  contraindi- 
cated  in  similar  disturbances  during  typhoid  fever. 
In  thrombosis  the  free  use  of  milk  (from  its  coagula- 
ting effect)  may  be  questionable,  unless  it  is  decalcified 
according  to  Wright's  method  by  the  addition  to  it  of 
.25  to  .6  per  cent  of  sodium  citrate  (20  to  40  grains  to 
the  pint). 

When  milk  is  well  digested  and  well  borne,  how- 
ever, as  it  is  in  the  majority  of  cases,  it  is  within  its 
limitations  one  of  the  best  of  foods,  and  must  consti- 
tute one  of  the  most  important  items  in  the  typhoid 
dietary.  Its  largest  content  of  salts  is  an  advanta- 
geous   feature,    and   during   the   febrile    period   may 


62  DIET   IN    TYPHOID   FEVER. 

materially  promote  coagulation  of  the  blood  and  hence 
tend  to  lessen  intestinal  hemorrhage.  From  its  bulk 
and  from  the  fact  that  it  is  especially  apt  to  disagree 
when  given  in  excessive  quantity,  it  is  quite  impracti- 
cable to  give  enough  milk  (3  liters  daily)  for  the  sole 
proper  nourishment  of  adult  patients;  and  it  would 
therefore  seem  that  it  should  necessarily  be  supple- 
mented by  more  concentrated  food.  The  necessity 
for  practically  confining  typhoid  diet  to  the  one 
article,  milk,  however  good  a  food  it  may  be,  and  for 
excluding  other  articles  that  would  afford  greater 
variety  and  more  nourishment,  is  not  obvious. 

Without  placing  any  exaggerated  faith  in  the  value 
or  exclusive  use  of  milk,  or  entertaining  any  undue 
fears  of  its  occasional  objectionable  action,  the  physi- 
cian should  exercise  the  same  critical  judgment  in  the 
employment  or  rejection  of  milk  in  each  individual 
case  as  in  the  use  of  any  other  food  stuff  or  medica- 
ment. 

With  a  view  to  increasing  digestibility  or  "  cutting 
the  curds,"  milk  is  often  given  peptonized,  in  the  form 
of  junket,  or  diluted  with  water,  lime-water,  etc.  The 
practice  of  giving  milk  diluted  is  open  to  the  objec- 
tions that  the  bulk  is  thus  increased  and  the  amount 
of  nutritive  material  that  can  be  given  decreased,  and 
that  the  concentration  of  the  gastric  juice  is  thus 
much  lowered.  Dilution  with  lime-water  or  other 
alkaline  fluid  is  open  to  the  further  objection  —  per- 
haps  more   theoretical    than    practical  —  that    these 


DIET   IN  TYPHOID   FEVER.  63 

alkalies  neutralize  hydrochloric  acid  in  the  gastric 
juice  and  may  thus  really  hamper  digestion.  The  use 
of  milk  with  a  minimal  bacterial  contamination,  or  of 
pasteurized  milk,  may  be  necessary  to  obviate  intes- 
tinal fermentation  and  indigestion. 

Cream,  if  well  borne,  ought  to  form  a  specially  val- 
uable item  in  the  typhoid  dietary,  since  from  its  high 
fat  content  it  has  nearly  three  times  the  energy  value 
of  milk.  If  the  fat  of  milk  is  badly  borne,  for  the 
sake  of  variety,  buttermilk  and  skimmed  milk  are 
available  for  use,  but  their  fuel  value  is  only  about  half 
that  of  milk. 

Soup. —  Soups,  broths,  bouillon,  beef  tea,  meat  ex- 
tracts, etc.,  are  at  present  extensively  used  in  typhoid 
feeding  as  substitutes  for  milk  or  for  the  sake  of  variety. 
These  articles  are  usually  satisfactorily  digestible,  lack 
some  of  the  special  objectionable  features  of  milk,  and 
markedly  stimulate  the  flow  of  gastric  juice.  Yet  not 
infrequently  broths  are  badly  borne  by  typhoid  pa- 
tients ;  and  of  the  diets  presented  in  Table  II,  the  com- 
bination of  soup  and  milk  shows  a  surprisingly  (and 
unexplainably)  low  digestibility  of  protein.  The  nitro- 
gen and  carbohydrate  contents  of  various  soups  differ 
much,  but  average  near  those  of  milk ;  the  fat  content 
runs  very  low  and  the  total  energy  value  of  soups  is 
in  general  much  lower  than  that  of  milk.  The  energy 
value  of  bouillon,  for  example,  averages  less  than  a 
sixth  that  of  milk.  The  nitrogenous  material  of  soups, 
broths,  etc.,  is  mainly  or  entirely  of  the  character  of 


64  DIET   IN   TYPHOID   FEVER. 

meat  extractives,  which  have  been  repeatedly  demon- 
strated to  be  quite  devoid  of  nutritive  value.  The 
high  estimation  in  which  they  are  held  by  the  laity  and 
the  generality  of  the  medical  profession  is  quite  unde- 
served, and  it  may  be  accepted  that  broths  and  the  like 
have  very  little  food  value  in  proportion  to  their  bulk  ; 
it  is  futile  to  attempt  to  give  an  adequate  amount  of 
nourishment  by  their  use  in  substitution  for  or  addi- 
tion to  milk;  patients  are  often  brought  to  a  state 
(unrecognized)  of  extreme  starvation  by  too  free  use 
of  them,  to  the  exclusion  of  useful  food  materials ;  and 
they  are  among  the  least  efficient  and  useful  articles 
for  typhoid  feeding. 

Barley  water  and  other  gruels  are  open  to  similar 
objections.  Soups  thickened  with  flour  or  starch,  or 
regular  porridges,  may,  however,  have  satisfactory 
nutritive  value  and  form  useful  foods. 

Eggs. —  One  hen's  egg  on  the  average  yields  about 
7.5  grams  of  protein,  5.3  grams  of  fat,  and  80  calories 
of  energy.  The  nitrogenous  and  fatty  constituents 
and  the  total  solids  of  eggs  are  among  the  most  highly 
digestible  of  all  foods, —  slightly  more  so  than  those 
of  milk.  Eggs  are  quite  free  from  objectionable  fea- 
tures, and  they  should  form  one  of  the  most  valuable 
articles  for  typhoid  diet,  especially  for  furnishing 
proteid. 

While  the  value  of  eggs  in  typhoid  feeding  is  gen- 
erally recognized,  there  are  great  differences  of  opin- 
ion and  practice  as  to  the  best  method  and  amount  of 


DIET   IN   TYPHOID   FEVER.  65 

administration.  Some  prefer  the  yolk,  others  the 
white.  The  yolk  contains  practically  all  the  fat  of 
egg,  is  richer  in  protein,  and  has  seven  times  the 
energy  value  of  an  equal  weight  of  the  white. 

Albumen  water  is  much  in  vogue  at  present,  made 
by  mixing  the  wliite  of  an  egg  with  a  considerable 
amount  of  water.  This  method  of  administration  is 
apparently  based  on  the  supposed  necessity  that  the 
food  be  liquid  and  dilute  in  typhoid.  This  is  an  ex- 
tremely inefficient  way  of  giving  egg.  Only  an  insig- 
nificant amount  of  food  material  can  be  thus  given, 
and  that  the  least  nutritious  part  of  the  egg.  No  rea- 
son is  apparent  for  supposing  that  egg  albumen  is 
more  digestible  in  this  dilute  and  liquid  form ;  on  the 
contrary,  the  dilution  might  weaken  the  action  of  the 
gastric  juice. 

It  would  seem  on  general  principles  that  the  best 
and  an  unobjectionable  way  of  giving  eggs  in  typhoid 
is  poached  or  soft-boiled ;  or,  if  the  patient  prefer,  raw 
or  even  hard-boiled  or  scrambled.  Beginning  with 
half  an  egg  or  a  whole  egg  a  day,  the  amount  may  be 
gradually  increased  until,  in  many  cases,  four  or  more 
eggs  are  taken  with  advantage  and  safely  daily. 

Custards  (preferably  steamed  or  baked)  and  plain 
ice  creams  are  highly  nutritious,  digestible,  and  pala- 
table, combining  as  they  do  the  elements  of  eggs,  milk, 
and  sugar,  and  to  those  not  committed  to  an  absolute 
liquid  diet  seem  almost  ideal  articles  for  use  in  typhoid 
fever.     Ice  cream  is  often  especially  well  borne  when 


66  DIET  IN  TYPHOID  FEVER 

there  is  gastric  irritability.  Egg-nog,  milk  punch,  and 
Stokes's  mixture  (2  egg  yolks,  50  c.  c.  of  brandy,  120 
c.  c.  of  aqua  aurantii  florum,  sugar  or  syrup  enough  to 
sweeten)  have  considerable  nutritive  as  well  as  stimu- 
lant value  and  are  eligible  for  use  when  such  a  combi- 
nation is  indicated. 

Meat. — It  may  seem  revolutionary  to  feed  meat  to 
typhoid  patients,  yet  most  of  the  advocates  of  liberal 
feeding  do  not  hesitate  to  do  so  under  proper  condi- 
tions, and  the  objections  commonly  raised  seemingly 
disappear  on  critical  examination.  Meat  is  the  most 
concentrated  and  most  efficient  natural  source  of  pro- 
teid,  and  is  one  of  the  most  digestible  and  least  irrita- 
ting of  all  foods.  The  protein  of  meat  is  in  health 
rather  more  digestible  than  that  of  milk.  The  total 
solids  of  meat  are  almost  entirely  absorbed,  leaving  in 
health  a  fecal  residue  of  only  4  or  5  per  cent  less 
than  milk.  If  properly  divided  before  reaching  the 
stomach,  meat  becomes  practically  fluid  in  the  alimen- 
tary passages,  forming  in  the  bowel  a  bland,  pasty, 
unirritating  mass  ;  to  insure  this  result,  it  is  only  nec- 
essary that  the  meat,  if  not  properly  masticated,  be 
given  in  minced  or  finely  divided  form.  For  these 
reasons  it  would  seem  as  if  meat,  instead  of  being  es- 
teemed the  worst,  should  be  regarded  as  a  perfectly 
eligible  food  for  typhoid  fever,  its  main  use  being  to 
furnish,  in  conjunction  with  milk  and  eggs,  the  pro- 
teid  needed.  No  one  contends  that  meat  should  be 
given  in  every  case,  or  that  it  would  be  needed  if  suf* 


DIET   IN   TYPHOID   FEVER.  67 

ficient  protein  could  be  obtained  from  other  sources ; 
but  it  is  held  that  the  alleged  dangers  of  meat  are 
largely  mythical,  and  that  if  for  any  reason  its  use  is 
desirable,  to  furnish  protein,  to  satisfy  the  patient's  ap- 
petite, or  for  other  objects,  there  need  be  no  hesita- 
tion in  giving  it. 

In  selecting  the  kind  of  meat,  the  least  digestible 
meats,  like  pork  and  veal,  may  be  excluded.  Oysters 
are  eligible  on  the  ground  of  digestibility  and  palata- 
bility,  but  from  their  low  nutritive  value  have  little 
efficiency.  Beef,  lamb,  chicken,  and  fish  are  regarded 
as  acceptable  for  typhoid  feeding  and  aflcord  considera- 
ble field  for  selection  and  variety.  These  all  have  a 
similar  protein  content,  15  to  24  per  cent,  but  vary 
much  in  fat  content,  from  practically  zero  to  20  or  30 
per  cent.  The  loin  steaks  of  beef  (sirloin,  tenderloin, 
porterhouse),  contain  much  more  fat  than  does  lean 
round  steak.  Lamb,  both  leg  and  chops,  is  rich  in  fat. 
Young  chicken  contains  little  fat;  fowl  and  turkey 
contain  more.  Most  fish  (bass,  cod,  flounder,  etc.)  are 
poor  in  fat ;  salmon  and  shad  are  among  those  contain- 
ing a  considerable  amount.  Meats  made  up  of  short 
and  loosely  united  muscle  fibers,  like  the  breast  of 
chicken  and  the  flaky  meat  of  fish,  are  more  digestible 
than  those  with  long  and  closely  united  fibers  ;  the 
more  fatty  meats  are  also  sometimes  somewhat  less  di- 
gestible. If  the  fatty  meats  are  well  digested,  how- 
ever, they  yield  much  more  energy  than  the  lean  ones. 
In  the  preparation  of  meat,  the  visible  fatty  and  indi- 


68  DIET   IN"   TYPHOID   FEVER. 

gestible  portions  should  be  removed;  it  should  be 
cooked  in  wholesome  manner,  as  by  broiling  or  roast- 
ing, and  finely  minced  either  before  or  after  cooking, 
provided  the  patient  is  unable  to  masticate  properly. 

Jellies. —  Chicken  jelly,  wine  jelly,  etc.,  are  nutri- 
tious, palatable,  digestible,  and  seemingly  unobjection- 
able, and  may  be  freely  and  advantageously  used. 
They  may  be  especially  and  liberally  employed  on  the 
occurrence  of  intestinal  hemorrhage,  to  take  advan- 
tage of  whatever  hemostatic  action  the  gelatin  may 
exert. 

Fats  are  the  richest  source  of  energy,  and  within 
the  limits  of  their  easy  digestibility  are  for  that  reason 
an  advantageous  ingredient  in  the  diet.  They  are  apt 
to  be  indigestible,  especially  in  large  amount,  and  to 
lower  the  digestibility  of  the  protein  with  which  they 
are  associated.  The  fat  in  Qgg,  milk,  and  butter  is 
highly  digestible ;  that  in  meat  slightly  less  so  ;  that  of 
vegetable  origin  much  less.  Given  as  freely  as  pos- 
sible within  the  limits  of  tolerance,  cream  and  butter 
should  seemingly  form  an  excellent  source  for  this 
class  of  food  in  the  typhoid  dietary.  It  has  been  rec- 
ommended that  fat  —  such  as  lanolin  —  be  adminis- 
tered by  inunction  or  rubbing  through  the  skin  when 
there  is  difficulty  in  giving  it  by  the  mouth  in  this 
disease  (Lehlbach);  but  it  is  doubtful  if  any  material 
amount  of  nutriment  can  be  introduced  in  this  way. 

Carhohydrates  and  vegetable  food.  Carbohydrates 
are  highly  digestible,  their  chief  disadvantage  being 


DIET   IN   TYPHOID   FEVER.  69 

that  they  may  ferment  and  produce  gas.  They  must 
be  relied  on  to  furnish  the  energy  required  beyond 
that  supplied  by  the  protein  ration  and  the  fat  that 
can  be  taken.  Except  for  the  sugar  in  milk,  we  must 
look  to  vegetable  products  for  our  supply  of  carbo- 
hydrate. Vegetable  food  has  two  disadvantages,  the 
low  digestibility  of  vegetable  protein  and  the  presence 
of  a  residue  of  undigestible  cellulose.  Vegetable  pro- 
tein is  about  15  to  25  per  cent  less  digestible  than  that 
of  animal  origin ;  and  although  vegetable  food  never- 
theless in  health  furnishes  an  efficient  supply  of  pro- 
tein, it  is  doubtless  advisable  to  look  to  animal  food 
for  the  bulk  of  the  proteid.  ration,  taking  only  such 
vegetable  protein  as  necessarily  accompanies  the  carbo- 
hydrate needed.  The  undigestible  cellulose  adds  to 
the  fecal  residue,  and  if  in  large  uadivided  masses  may 
conceivably  cause  intestinal  injury  in  typhoid  fever- 
Different  vegetable  foods  vary  much  in  the  amount  of 
fecal  residue ;  white  wheat  bread  yielding  (in  health) 
only  about  5  per  cent,  vegetables  two  or  three  times 
as  much.  For  the  typhoid  dietary  vegetable  foods  can 
be  selected  that  yield  the  smallest  undigested  residue ; 
fibrous  and  membranous  vegetable  tissue,  skins,  seeds, 
etc.,  being  excluded ;  and  the  vegetable  material  used 
being  finely  divided  and  having  its  cellulose  well 
broken  up,  by  mechanical  means  (flour,  cornstarch),  by 
thorough  cooking  (rice,  potato),  or  otherwise. 

Theoretically  the  most  efficient  form  of  carbohydrate 
food  is  sugar,  which  is  pure  and  free  from  cellulose. 


70  DIET  IN   TYPHOID  FEVER. 

protein,  and  fat,  and  being  the  end-product  of  carbohy- 
drate digestion  should  be  immediately  absorbable  with- 
out requiring  any  digestive  preparation.  For  these 
reasons,  sugar,  syrups,  honey,  etc.,  might  well  be  intro- 
duced into  the  food  for  the  typhoid  patient  as  liberally 
as  possible.  Unfortunately  sugar  is  not  tolerated  as 
food  in  unlimited  quantities  ;  and  typhoid  patients  often 
seem  especially  intolerant  of  it.  Possibly  other  sugars 
than  cane  sugar,  as  maltose,  would  be  better  borne. 

Cornstarch  is  regarded  by  the  advocates  of  soft  diet 
as  a  very  useful  material  for  typhoid  feeding,  given  in 
the  form  of  puddings,  blanc  mange,  chocolate  pudding, 
etc.,  or  used  to  thicken  soups.  Rice  and  other  cereals, 
thoroughly  cooked,  flour  products  like  milk  toast,  bread 
or  crackers  or  milk,  bread  and  butter,  and  bread 
pudding,  also  mealy  baked  potato,  are  also  available, 
cautiously  introduced. 

Fruits  have  low  energy  value,  and  the  chief  use  of 
such  as  are  admissible,  as  the  pulp  of  baked  apple, 
orange  juice,  etc.,  would  be  to  add  relish  to  the  diet  or 
act  on  the  bowels. 

Beverages. —  Coffee  and  tea  are  allowable  as  bever- 
ages or  for  their  stimulant  action,  though  they  have 
little  nutritive  value.  Cocoa  often  makes  a  welcome 
addition  to  the  typhoid  diet,  and  has  food  value. 

Alcohol  has  been  shown  to  be  capable  in  health  of 
furnishing  a  portion  of  the  energy  needed  for  the 
body,  taking  the  place  of  fat  and  carbohydrate  for  this 
purpose,  and  to  this  extent  it  is  a  food.     Whether,  in 


DIET  IN   TYPHOID  FEVER.  71 

view  of  other  possible  counterbalancing  detrimental 
effects,  it  would  be  advisable  to  use  alcohol  regularly 
for  its  food  and  energy  value  in  typhoid  fever  is  an 
open  question.  If  its  use  were  advisable  it  would 
have  the  advantage  of  being  easily  absorbable,  and  of 
having  high  caloric  value. 

Proprietary  foods. —  There  are  a  large  number  of 
predigested  and  otherwise  specifically  prepared  foods 
on  the  market  which  are  highly  exploited  by  their 
proprietors  for  use  in  disease  conditions,  typhoid  fever 
included.  Most  of  these  foods  yield  but  a  small 
amount  of  actual  nutriment  in  comparison  with  what 
is  needed  by  the  body  or  what  is  afforded  by  ordinary 
food.  Experiments  (in  health)  do  not  show  any  great 
difference  between  the  absorbability  or  efficiency  of 
native  albumins  and  artificially  predigested  proteids 
(albumoses  and  peptones).  Meat  extracts  and  meat 
juices  yield  an  insignificant  and  entirely  inadequate 
amount  of  utilizable  nitrogenous  material.  The  foods 
described  as  "  predigested  carbohydrates  "  are  simply 
one  or  another  kind  of  sugar.  Most  of  the  liquid  pro- 
prietary foods  contain  from  10  to  25  per  cent  of  alcohol, 
and  if  given  in  the  quantities  recommended  are  not 
only  insufficient  for  nourishment,  but  yield  a  dosage 
of  alcohol  which  should  be  distinctly  recognized  and 
and  appreciated  by  the  physician.  Ordinary  food  if 
satisfactorily  digested  is  far  superior  to  proprietary 
foods.  The  only  field  of  usefulness  for  the  latter  in 
typhoid  fever  is  found  in  the  cases  in  which  there  is 


72  DIET   IN   TYPHOID   FEVER. 

great  gastric  intolerance  of  food;  in  such  cases  the 
proprietary  foods  may  be  tried  in  the  hope  that  some 
of  them  may  be  borne  by  the  stomach,  and  such  nutri- 
ment and  stimulant  as  they  yield  may  be  utilized. 

The  acceptability  of  various  food  articles  for  the 
typhoid  dietary  has  now  been  considered  in  critical 
detail,  and  their  sufficiency  to  meet  what  seem  to  be 
the  essential  requirements  of  an  adequate  and  safe 
diet  in  this  disease.  The  list  is  quite  extensive,  afford- 
ing considerable  field  for  selection ;  the  articles  men- 
tioned are  all  such  as  are  recommended  by  advocates 
of  a  more  liberal  and  varied  diet  than  is  now  custom- 
ary ;  and  a  consideration  of  the  dietetic  and  physiologic 
principles  involved,  as  well  as  the  results  of  actual 
practice,  indicates  that  they  may  be  safely  and  advan- 
tageously employed. 

The  diet  list  available  for  typhoid  feeding  may  be 
summarized  as  follows : 

Milk,  raw,  pasteurized,  peptonized,  decalcified,  or 
otherwise  modified ;  cream,  skimmed  milk,  buttermilk, 
junket,  butter. 

Soups,  broths,  gruels ;  especially  thickened  with 
flour  or  corn  starch. 

Eggs. 

Custards  ;  ice  cream  ;  eggnog  or  Stokes's  mixture. 

Meat ;  beef,  lamb,  chicken,  fish ;  minced,  etc. 

Jellies. 

Cornstarch  pudding,  chocolate  pudding,  rice  and  ce- 
reals, milk  toast,  bread  or  crackers  and  milk,  bread  and 


DIET  IN  TYPHOID  FEVER.  73 

butter,  bread  pudding,  sago  or  tapioca  pudding,  por- 
ridges, baked  potato,  fruit,  sugar. 

Coffee,  tea,  cocoa,  alcoholic  drinks. 

Proprietary  foods. 

METHOD    OF    FEEDING. 

Success  and  safety  in  liberal  feeding  depend  not 
only  on  the  kind  of  food,  but  also  on  the  manner  in 
which  it  is  given.  Each  case  should  be  individualized 
and  managed  on  its  own  merits ;  the  patient  should 
be  treated  "  rather  than  the  name  of  his  disease."  The 
supervision  of  every  detail  of  the  feeding  will  require 
and  repay  the  constant  attention  of  the  physician. 
The  intervals  between  feedings  should  not  be  less  than 
two  hours,  perhaps  more.  The  feedings  should  be 
timed  to  follow  and  not  precede  the  baths. 

The  advocates  of  liberal  diet  are  unanimous  in  fol- 
lowing, as  the  main  guide  in  feeding,  the  patient's  ap- 
petite and  digestive  powers.  Due  attention  is,  of 
course,  paid  to  the  general  condition,  but  the  tempera- 
ture is  left  largely  out  of  consideration,  and  need  cause 
no  great  hesitation  in  feeding.  Hunger  is  taken  as  a 
reliable  indication  that  food  is  needed  and  can  be  as- 
similated ;  and  whenever  a  genuine  appetite  and  de- 
sire for  food  is  evinced,  when  the  patient  answers  af- 
firmatively to  the  daily  question,  "Are  you  hungry?" 
there  should  be  no  hesitation  in  immediately  increas- 
ing his  diet  and  putting  it  on  a  generous  basis. 


74  DIET  IN   TYPHOID   FEVER. 

Food  should  not  ordinarily  be  forced  or  urged  un- 
duly on  an  unwilling  patient,  nor  should  he  be  per- 
mitted to  gorge  himself  to  an  uncomfortable  stage  of 
excessive  satiety.  It  is  possible,  however,  that  pa- 
tients in  a  low,  nervous,  restless  condition,  who  obsti- 
nately resist  taking  nourishment,  and  who  are  apt  to 
do  badly  and  whose  nutrition  becomes  greatly  lowered, 
might  be  benefited  by  forced  feeding ;  and  if,  as  fre- 
quently occurs  in  these  cases,  there  is  much  gastric  ir- 
ritability and  intolerance  of  food,  gastric  lavage  and 
gavage  may  produce  good  results. 

Abrupt  changes  should  be  avoided,  and  increase  in 
the  amount  of  food  should  be  made  gradually,  with 
careful  observation  of  the  accompanying  effects.  In 
many  cases  the  appetite  continues  from  the  first,  and 
is  not  at  anytime  completely  lost;  in  such  the  feeding 
may  be  more  or  less  liberal  from  the  beginning.  In 
cases  in  which  the  appetite  is  entirely  lost  and  the  diet 
falls  to  a  low  plane,  the  food  should  be  carefully  and 
gradually  increased  when  the  appetite  returns. 

When  there  is  extreme  gastric  intolerance  of  food 
and  nutrition  is  greatly  lowered,  rectal  and  possibly 
also  subcutaneous  ahmentation  may  be  employed  in 
order  to  obtain  whatever  benefit  these  procedures  are 
capable  of  affording. 

PRACTICAL    RESULTS. 

The  final  settlement  of  the  question  of  liberal  feed- 
ing in  typhoid  fever  must  rest,  not  on  theoretical  con- 


DIET  IN  TYPHOID   FEVER. 


75 


siderations,  but  on  the  results  of  actual  trial  and  ex- 
perience, and  the  demonstration  of  superior  advantages 
and  efficiency  for  the  method.  Numerous  observers 
in  all  parts  of  the  world,  Russia,  Australia,  England, 
America,  have  reported  results  with  an  enlarged  dietary. 

A  notable  and  forceful  contribution  in  advocacy  of 
generous  feeding  in  typhoid  fever,  based  on  31  cases, 
was  made  by  Barrs  (England)  in  1897,  which  has  at- 
tracted much  attention. 

In  1900  Marsden,  of  Manchester,  reported  the 
results  of  treatment  of  200  consecutive  typhoid  cases 
according  to  the  methods  of  Barrs.  He  does  not 
mention  his  mortality,  but  there  was  no  case  of  per- 
foration, only  six  of  hemorrhage,  relapses  were  no  more 
numerous  than  the  average,  and  in  no  instance  were  any 
of  the  complications  clearly  chargeable   to  the  diet. 

Bushuyeff  of  Russia,  in  18 9 5-' 9 6  out  of  154  hospital 
patients,  treated  80  on  a  diet  consisting  chiefly  of 
bread  and  meat,  while  a  colleague  who  adhered  to  the 
orthodox  system  treated  the  other  74  chiefly  on  milk. 
The  comparative  average  results  were : 

Recoveked. 


Number  of  patients 

Average  day  of  illness  on  admission  . . . . 
Duration  of  fever  after  admission,  days. 

Duration  of  stay  in  hospital,  days 

Day  on  vrhich  recovery  was  complete. . . 
Incapable  of  duty  on  dismissal: 

Number 

Per  cent 


Mixed  diet. 

Milk  diet. 

72 

65 

7.5 

5.8 

18.9 

22.3 

42 

49.2 

49.5 

55 

6 

10 

8.3 

15.4 

76 


DIET  IN   TYPHOID   FEVER. 
Died. 


Mixed  diet. 

Milk  diet. 

Number 

8 
10 

8. .5 
28.6 

9 

Per  cent 

12  1 

Average  day  of  illness  on  admission 

Average  day  of  death 

.5.8 

26.7 

During  1897,  out  of  318  patients  on  the  solid  diet, 
Bushuyeff  lost  26,  or  8.2  per  cent,  the  average  typhoid 
mortality  of  the  hospital  for  the  10  years  previous  be- 
ing 12.4  per  cent. 

Metabolism  studies  and  liberal  feeding  in  typhoid 
fever  have  been  especially  carried  out  by  Russian  ob- 
servers. The  mortality  statistics  in  typhoid  patients 
treated  on  a  generous  diet  by  Russian  authorities  are 
summarized  by  Pauline  Gourari  (1901)  as  follows : 


Number  of  Cases. 

Numberof  Deaths. 

Mortality, 
Per  cent. 

Kassetzky 

180 
276 
150 
[398 
96 

10 
11 
4 
34 
10 

5.5 

Kissel 

4 

Gournitzki 

2.7 

Bushuyeff 

8.6] 
10.9 

Timen 

Total 

1,100 

69 

6.3 

These  mortality  rates  are  almost  incredibly  low. 

Brummitt,  of  Australia,  in  1901  reported  98  cases 
fed  on  bread,  milk,  minced  meat,  eggs,  etc.,  with  5 
deaths. 

In  the  United  States,  the  leading  advocate  of  gen- 
erous feeding  in  typhoid  fever,  in  the  boldness  of  his 


DIET  IN   TYPHOID   FEVER. 


77 


methods,  the  vigor  of  his  arguments,  and  the  extent  of 
his  experience,  has  been  Shattuck,  of  Boston.  During 
1886  to  1893,  he  treated  233  patients  on  exclusive 
milk  diet,  with  a  mortality  of  10  per  cent ;  from  1893 
to  1902,  with  246  patients  hberally  fed,  he  had  a 
mortality  of  8.45  per  cent.  Hemorrhage,  perforation, 
and  relapses  were  not  increased  in  frequency. 

In  a  study  of  the  statistics  of  typhoid  fever  at  the 
Massachusetts  General  Hospital,  to  1899,  presented  by 
Fitz,  further  comparisons  may  be  made  between  the 
patients  of  Shattuck,  which  are  included  in  the  statis- 
tics, and  those  treated  by  his  colleagues  on  the  usual 
restricted  diet,  as  follows : 


Kinnicut,  of  New  York  (1906),  reports  74  cases  well 
fed,  with  9  deaths.  He  presents  the  following  analysis 
of  reported  statistics  showing  comparative  results  in 
patients  fed  on  the  liberal  and  the  milk  diet : 


Liberal  diet. 

Milk  diet. 

Total  numbers  of  cases 

Relapses  (based  on  325  well-fed  cases),  per  cent 

Hemorrhage,  fatal  cases,  per  cent 

Perforation,  fatal  cases,  per  cent 

Mortality  (based  on  633  well-fed  cases),   per 
cent 

733 
11.4 
4.8 
1.4 

9.5 

4,654 
10.9 
8.8 
2.4 

10.6 

78 


DIET  IN   TYPHOID  FEVEK. 


Manges,  Le  Fevre,  Hare,  Claytor,  and  numerous 
others,  in  this  and  other  countries,  have  also  presented 
favorable  views  and  results  from  the  generous  feeding 
of  typhoid  patients. 

From  the  reports  covering  considerable  series  of 
cases  may  be  collected  the  following  1518  .cases  of 
typhoid  fever  treated  with  the  enlarged  diet,  with  104 
deaths,  a  mortality  of  6.9  per  cent. 


Cases. 

Deaths. 

Russian  observers 

1,100 

98 

246 

74 

69 

Brummitt 

Shattuck 

5 

21 

Kinnicutt 

9 

Total 

1,518 

104 

In  the  cases  of  typhoid  fever  treated  by  more  or  lesp 
liberal  feeding  that  have  come  under  my  own  care 
or  observation,  forty  or  more  in  number,  the  same 
highly  satisfactory  and  gratifying  results  noted  by  other 
writers  on  the  subject  have  been  found  by  me,  and  in 
not  a  single  instance  was  there  any  bad  effect  resulting 
from  the  food  given. 

Among  all  the  reports  that  I  have  found,  not  one  ob- 
server who  has  given  the  liberal  diet  a  candid  and  sin- 
cere trial  condemns  it.  All  agree  that  the  evil  results 
generally  feared  were  not  produced.  Tympanites, 
diarrhea,  hemorrhage,  perforation,  and  relapse  did  not 
seem  to  be  increased  in  frequency,  if  indeed  they  were 


DIET   IN  TYPHOID   FEVEE.  79 

not  decreased.  The  general  average  mortality  of  6.9 
per  cent  just  noted  certainly  does  not  support  the  pre- 
vailing notions  as  to  the  dangers  of  mixed  feeding. 

The  liberal  diet  to  be  justified,  however,  must  have 
not  only  the  mere  negative  quality  of  safety,  but  must 
present  positive  advantages  and  superiority  of  efficiency 
and  results  over  the  present  system.  Those  who  have 
given  generous  feeding  in  typhoid  fever  a  trial  are  quite 
unanimous  and  emphatic  in  the  expression  of  their 
convictions  that  the  method  is  far  superior  in  its  results  to 
the  present  restricted  diet.  The  special  advantages  that 
have  been  observed  or  may  be  expected  are  the  following : 

The  comfort  and  contentment  of  the  patients  are  far 
greater  under  generous  feeding  than  under  the  cus- 
tomary diet.  The  writers  are  unanimous  in  their  em- 
phatic and  gratified  expressions  on  this  point.  The  pa- 
tients suffer  much  less  from  hunger,  and,  especially, 
the  distressing  hunger  ordinarily  present  in  the  early 
convalescent  period,  while  not  entirely  abolished,  is 
greatly  diminished,  and  the  temptation  to  indulge  sur- 
reptitiously in  forbidden  food  is  much  lessened. 

With  a  large  diet  list  to  choose  from,  the  special  lik- 
ings of  the  patient  can  be  met  and  greater  variety  in- 
troduced into  the  feeding.  In  case  of  indigestion  and 
intolerance  of  food,  with  a  large  list  to  select  from 
there  is  a  greater  chance  of  being  able  to  find  some 
food  that  is  satisfactorily  borne  by  the  stomach,  while 
the  physician  who  uses  only  milk  and  soup  is  at  a  loss 
what  to  do  when  these  disagree. 


80  DIET  IN   TYPHOID  FEVER. 

The  adequate  diet  should,  so  far  as  is  possible  in  this 
disease,  eliminate  the  effects  of  starvation;  and  it  is 
probable  that  it  is  not  even  yet  entirely  known  what 
symptoms  are  due  to  insufficient  nutrition  and  what  to 
the  disease  proper. 

For  example,  the  subnormal  temperature  character- 
istic of  the  beginning  of  the  apyretic  period  is  undoubt- 
edly a  starvation  symptom,  due  to  the  fact  that  at  that 
time  the  organism  having  regained  the  power  of  ana- 
bolism  greedily  stores  up  food  material  in  its  tissues, 
and  if  the  food  supply  is  inadequate  does  not  liberate 
enough  food  energy  to  maintain  body  temperature. 
In  patients  well  fed  during  the  pyrexia  the  depression 
of  body  temperature  of  early  convalescence  is  usually 
much  less  in  range  and  duration  than  in  ill-fed  patients ; 
and  it  is  possible  to  tell  from  the  temperature  chart  in 
most  cases  how  the  patient  has  been  fed  and  nourished. 
While  it  has  not  been  customary  to  attach  any  great 
significance  to  the  marked  post  febrile  depressions  of 
temperatiu-e  ordinarily  seen,  they  even  being  regarded 
with  satisfaction  as  a  harbinger  of  convalesence,  it  is 
highly  probable  that  when  excessive  they  indicate  un- 
duly lowered  nutrition  and  insufficient  feeding.  The 
temperature  range  at  this  period  of  the  disease  is  there- 
fore an  index  of  the  patient's  nutrition  and  dietetic 
management,  and  a  minimum  of  subnormal  tempera- 
ture is  a  testimony  of  proper  feeding. 

The  accompanying  temperature  chart  illustrates  typi- 
cally the  effect  of  feeding  on  the  post-febrile  tempersr 


Temperature    chart    of    A.    C,    during    and    following    defer 
fever,    illustrating    effect    of    diet    on    the    temperature.      Liberal 
broth   after    September 


DIET  IN   TYPHOID   FEVER.  gX 

ture.  The  patient  was  fed  on  a  generous  mixed  diet 
during  the  primary  period  of  pyrexia,  but  on  the  oc- 
currence of  a  relapse  received  the  conventional  milk 
and  broth  diet.  Following  the  primary  pyrexia  the 
temperature  did  not  fall  below  98° ;  following  the  re- 
lapse the  temperature  was  markedly  and  continuously 
depressed,  ranging  between  96.6°  and  98°. 

The  patient's  strength,  nutrition,  and  general  condi- 
tion should  be  better  maintained  on  the  liberal  diet. 
On  theoretical  grounds  no  lowering  of  the  fever  is  to 
be  expected  with  a  large  diet ;  but  if  there  is  any  in- 
crease in  the  patient's  powers  of  reacting  against  the 
disease,  a  shortening  of  the  period  of  pyrexia  might  be 
expected.  So  far  as  can  be  judged  from  general  im- 
pressions, in  the  absence  as  yet  of  sufficient  exact 
comparative  statistics,  it  is  probable  that  liberal  feed- 
ing may  be  shown  to  be  capable  of  slightly  shortening 
the  course  of  the  fever.  There  is  general  and  positive 
agreement  among  the  writers  that  the  duration  of  con- 
valescence is  materially  shortened  in  the  well-fed  pa- 
tients. This  is  to  be  expected,  since  the  less  the  pa- 
tient is  allowed  to  lose  the  less  he  has  to  regain ;  and 
the  customary  delay  of  seven  to  ten  days  after  the 
fever  subsides,  before  the  resumption  of  feeding,  is 
done  away  with. 

Writers  on  the  subject  make  little  mention  of  the 
effect  of  free  diet  on  the  nervous  complications  and 
profound  toxemic  conditions  sometimes  occurring  in 
typhoid  cases.     In  cases  presenting  these  complications 


82  DIET  IN  TYPHOID   FEVER. 

it  is  often  difficult  to  administer  food  even  in  small 
quantities,  and  it  is  probable  that  these  bad  conditions 
are  made  much  worse  by  the  aggravated  innutrition 
thereby  enforced.  It  is  these  cases  in  which  it  is 
practically  impossible  to  feed  at  all  that  swell  the  mor- 
tality rates  in  typhoid  fever. 

The  better  maintenance  of  strength  and  nutrition 
through  ample  feeding  should  be  manifested  in  the 
long  run  by  a  lowering  of  the  death  rate,  since  in  cases 
in  which  the  issue  is  delicately  balanced  the  bettered 
nutritive  condition  may  turn  the  scale  in  favor  of  re- 
covery. The  statistics  of  Shattuck  and  Bushuyeff,  so 
far  as  they  go,  show  a  difference  in  mortality  of  from 
1.5  to  4  per  cent  in  favor  of  the  liberal  diet. 

While  the  practice  of  generous  feeding  in  typhoid 
fever  will  seem  revolutionary  to  most  physicians  and 
is  contrary  to  the  teachings  of  most  of  the  clinical 
leaders  and  manuals  of  medicine,  yet  it  has  the  ap- 
proval of  some  of  the  very  highest  authorities.  It  is 
the  belief  of  its  advocates  that  the  fears  of  deleterious 
consequences  generally  held  against  mixed  feeding  in 
typhoid  fever  are  groundless.  All  the  complications 
which  it  is  generally  asserted  would  arise  from  the  use 
of  soft  and  solid  food  occur  under  the  strictest  milk 
regimen.  While  it  is  recognized  that  dietetic  impro- 
prieties may  cause  trouble  in  typhoid  fever,  as  great 
and  even  greater  trouble  and  danger  can  be  caused  by 
the  improper  use  of  milk  as  by  any  other  food.  Even 
if  in  some  one  respect  mixed  diet  were  deleterious  and 


DIET   IN   TYPHOID  FEVER.  83 

yet  on  the  whole  its  general  effects  were  beneficial,  its 
use  would  be  warranted ;  just  as,  in  spite  of  the  ad- 
mitted fact  that  the  cold-bath  treatment  seemingly  in- 
creases the  frequency  of  hemorrhages  and  relapses  in 
typhoid  fever,  the  bath  method  is  nevertheless  ap- 
proved. 

The  object  and  the  advantage  of  adequate  feeding 
in  typhoid  fever  (as  in  other  conditions)  is  the  mainte- 
nance of  body  nutrition  at  the  highest  point  possible 
under  the  circumstances.  In  other  diseases,  as  tuber- 
culosis, indigestion,  and  the  like,  the  importance  of  at- 
taining a  high  state  of  nutrition  —  the  measure  and 
index  of  which  is  the  body-weight  —  is  generally  ap- 
preciated. In  typhoid  fever  the  condition  of  body 
nutrition  and  the  dangers  of  malnutrition  are  as  gen- 
erally quite  ignored ;  yet  there  is  no  reason  to  suppose 
that  the  organism  suffering  from  typhoid  fever  is  not 
subject  to  the  same  laws  of  nutrition,  metabolism,  and 
dietetics  as  apply  under  other  circumstances.  If  it 
could  be  made  practicable  to  weigh  typhoid  fever  pa- 
tients at  proper  short  intervals,  so  that  changes  in 
body  nutrition  could  be  followed  as  closely  and  exactly 
as  can  changes  in  body  temperature,  the  weight  record 
in  its  bearings  on  treatment  and  prognosis  might  be 
found  to  have  a  practical  importance  approaching  that 
of  the  temperature  record;  and  the  reduction  of 
emaciation  to  a  minimum  might  be  found  an  object  in 
its  actual  results  worthy  of  the  keenest  and  most  solici- 
tous endeavors  of  the  physician. 


84  DIET   IN  TYPHOID   FEVER. 

The  evolution  of  the  current  methods  of  feeding  in 
typhoid  fever  seems  to  have  been  largely  fortuitous 
and  empirical,  and  the  present  practice  has  not  been 
established  on  or  subjected  to  the  critique  of  scientific 
dietetic  and  physiologic  principles,  as  has  been  done, 
for  instance,  in  the  matter  of  infant  feeding.  The  his- 
tory of  feeding  in  fever  shows  a  progressive  advance 
from  a  starvation  regimen  in  the  direction  of  more  and 
more  liberal  diet. 

Methods  and  foods  in  one  epoch  regarded  as  highly 
injudicious  and  dangerous  have,  in  succeeding  periods, 
come  into  general  use,  and  the  feared  objections  proven 
groundless.  We  have  come  to  the  use  of  a  diet  of 
medium  nutritive  value,  but  there  is  still  room  for 
further  advance.  In  the  antiphlogistic  era  the  pro- 
fession imbibed  a  deep  seated  fear  of  giving  food  in 
many  diseases,  that  caused  enormous  harm  by  delib- 
erate and  wholesale  starvation  of  patients. 

The  habit  of  antiphlogistic  therapy  was  through 
centuries  of  belief  and  practice  firmly  impressed  on  the 
professional  mind,  and  it  has  been  with  difficulty  and 
with  fearful  and  cautious  steps  that  the  profession  was 
emancipated  from  that  practice.  Indeed,  vestiges  of 
the  antiphlogistic  habit  are  still  apparent  in  the  treat- 
ment of  fever ;  physicians  no  longer  bleed  and  purge 
and  puke  their  patients  to  death ;  but  they  still  par- 
tially starve  them,  and  practice  with  complacency  and 
good  faith  a  system  that  subjects  the  sufferers  to  the 
tortures   of   the   most   distressing   hunger    and  semi- 


DIET   m   TYPHOID    FEVER.  85 

starvation  for  weeks.  Much  harm  is  still  caused  by 
needlessly  starving  patients,  not  only  in  typhoid  fever, 
but  in  other  conditions.  Physicians  ought  to  be  just 
as  solicitous  about  the  very  real  and  certain  dangers 
of  starvation  as  they  now  are  about  the  occasional  or 
fancied  or  mythical  evil  results  of  feeding ;  and  if  they 
were  as  bold  in  giving  food  as  they  are  now  willing  to 
withhold  it,  results  might  in  many  instances  be  better. 
The  argument  is  often  offered  that  the  superiority 
of  the  present  dietetic  methods  in  typhoid  is  shown 
by  universal  experience  and  approval.  The  appeal  to 
universal  practice  and  experience  on  its  face  seems  a 
strong  argument,  yet  a  consideration  of  the  history  of 
medicine  shows  that  it  is  an  argument  to  be  accepted 
with  great  reserve.  There  have  been  scores  of  theo- 
ries and  systems  and  methods  of  practice  that  for  a 
time  enjoyed  universal  approval  and  claimed  justifica- 
tion on  the  ground  of  the  results  of  general  experience, 
which  nevertheless  in  the  end  were  found  erroneous 
and  were  utterly  discarded.  What  general  experience 
may  fairly  be  claimed  to  have  demonstrated  in  the 
matter  of  typhoid  feeding  is  this,  that  the  present 
milk  diet,  one  of  medium  nutritiousness,  gives  better 
results  than  any  of  the  more  restricted  diets  previously 
in  use.  An  equally  general  trial  of  a  diet  even  more 
liberal  than  the  present  one  might  give  a  showing  of 
results  better  still.  The  claim  that  experience  has 
shown  the  essential  danger  and  inadmissibility  of  a 
diet  more  generous  than  the  present  one,  or  of  the 


86  DIET  IN  TYPHOID  FEVER. 

use  of  solid  or  soft  food,  is  open  to  this  objection,  that 
such  liberal  feeding  has  never  been  given  widespread 
trial,  and  there  has  been  no  general  experience  with  it 
to  show  its  inadvisability.  The  starvation  treatment 
was  once  universally  tried  and  universally  condemned 
by  the  profession ;  the  present  medium  diet  has  like- 
wise been  universally  tried  and  found  more  satisfactory. 
Trial  of  liberal  mixed  diet  has  not,  however,  been 
made  on  a  like  extensive  scale ;  and  if  its  advantages 
have  not  had  a  chance  for  demonstration,  neither 
have  its  alleged  dangers  been  really  shown.  The 
grave  fears  once  entertained  of  the  use  of  milk  and 
broth  were  shown  by  actual  trial  to  have  been  ground- 
less; and  the  present  similar  fears  of  soft  and  sohd 
food  might  likewise,  on  trial,  prove  to  be  unfounded. 
Because  a  ravenous  starved  patient  develops  a  fever 
(almost  always  brief  and  harmless)  from  surreptitious 
over-indulgence  in  unaccustomed  food  is  no  proof  that 
a  liberal  and  varied  diet,  properly  regulated,  is  essen- 
tially harmful ;  nor  does  the  fact  that  most  patients 
recover  on  milk  prove  that  other  food  is  dangerous. 

Some  of  the  conclusions  and  estimates  presented  in 
this  study  are  of  a  tentative  character,  based  on  such 
data  as  are  now  available  and  subject  to  such  revision 
as  may  be  required  by  future  investigations.  Some  of 
the  directions  in  which  further  studies  can  be  advan- 
tageously prosecuted  for  the  more  precise  settlement 
of  the  questions  involved  are  :  metabolism  studies,  es- 
pecially  of   nitrogenous   exchanges   with   the   larger 


DIET   IN   TYPHOID   FEVER.  87 

amounts  of  nitrogen  in  the  food,  the  effect  of  varying 
amounts  of  carbohydrates  and  fats  in  lessening  nitro- 
genous waste,  etc.,  to  determine  the  optimum  proteid 
ration ;  a  close  study  of  body-weight  changes  as  influ- 
enced by  food  of  diif  erent  amounts  and  different  kinds  ; 
and  above  all  a  closer  determination  of  the  total  en- 
ergy requirement  in  fever,  such  as  could  be  best  ob- 
tained only  by  accurate  measurements  of  the  carbon, 
hydrogen,  and  oxygen  exchanges,  and  especially  by 
calorimetric  investigations. 

While  further  investigations  are  desirable  to  settle 
some  of  the  details,  it  is  believed  that  the  data  already 
available  are  ample  to  warrant  the  conclusion  that  a 
generous  and  varied  diet  yields  by  far  the  best  results 
in  the  treatment  of  typhoid  fever.  If,  indeed,  liberal 
feeding  can  effect  a  lowering  of  anywhere  near  two 
per  cent  in  the  general  mortality  of  typhoid  fever,  the 
aggregate  results  attainable  would  be  of  the  highest 
order. 


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